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A MANUAL

TREATMENT BY MASSAGE

AND

METHODICAL MUSCLE EXERCISE.

JOSEPH SCHKEIBEK, M.D.,

MEMBEE OF K. K. OESELLBCHAFT DEE AERZTE OF VIENNA; FOBMEELY DOCENT IN THE UNIVERSITY OF
VIENNA ; FOREIGN MEMBER OF THE FRANCAISE d'HYQI^NE, OF THE BOCI6t£:

O’HYDUOLOGIE M<^:DICALE of PARIB; COBBEBPONDING member OF THE B0CI^'T(:

I>E MfiPEOINE ET DE CLIMATOLOGIE OF NICE; PROPRIETOR AND
* DIRECTOR OF THE SANITARIUM “aEPENHIIM,” IN
AUSSEE, STYBIA, AUSTRIA.

TRANSLATED, WITH THE AUTHOR’S PERMISSION,

WALTER MENDELSON, M.D.

OF NEW YORK.

EDINBUKGH:

YOVl^G J. PENTLAND.

PREFACE TO THE AMERICAN EDITION.

The growing tendency of modern therapeutics to do away as far
as possible with the use of drugs, and to seek to cure disease by the
application of the laws of hygiene, has made it seem desirable to
present to the medical public a practical work on that oldest branch
of the healing art, namely, rnechano-therapy.

With this end in view, the following translation of a work by an
eminent practitioner of the art has been prepared by permission of
the author. It is the hope of the translator and publishers that its
dissemination may serve the purpose of more extensively introducing
the use of this simple yet efficacious means of treating many painful
diseases, and so may contribute to the relief of suffering humanity.

W. M.

Nbw York, 1887.

PREFACE TO THE GERMAN EDITION.

My object in writing this work has been to afford the practising
physician a trusty guide to the noiechanical treatment of disease.

During its preparation — which was greatly prolonged owing to
the time required to furnish the necessary illustrations — no less than
four large works on the same subject appeared in the German
language, namely, those of Rossbach, Busch, Reibmeyer, and
Samuely.

I confess that the successive appearance of these caused in me no
little alarm, for I could not suppress in myself the feeling that each
of them might make my own work unnecessary, not to mention
laying it under the suspicion of being a mere plagiarism.

However, these fears have proved to be without foundation, for I
think I have succeeded in presenting my subject from a new point
of view, and thus filling a gap in the literature of mechano-therapy.

Throughout it has been my endeavor to elucidate the mechanical
method by citations of cases which have come within my personal
observation, and to call attention to both peculiar and unforeseen
difficulties, as well as to introduce, wherever possible, such practical
hints as will facilitate the execution of the various manipulations.

Should this work fulfil these expressed intentions, I feel that it
may be a not unwelcome offering to many of my colleagues.

THE AUTHOR.

Aussbe, Styria, Austria.

CONTENTS

Introduction.

History of Mechano-therapy.

The Ling method 23

CHAPTEE I.

Definition of Massage.

Why mechano-therapy has not bcc()me the common property of the pro-
fession 32

On learning massage without a teacher 36

Use of massage by the general practitioner 37

Use of massage by non-physicians 38

Substitution of the hand by apparatus ....... 39

Conclusions 40

CHAPTEE II.

Physiological Effects of Massage.

I. Primary . . 41

II. Secondary 44

Generation of heat during mechanical vibration 49

CHAPTEE III.

Description of Mechanical Interferences.

Classification of same 63

I. Stabile ............ 64

Pressing ........... 64

Tapping, thrusting, and hacking 68

Klemm’s muscle-beater 62

Pinching 64

Squeezing 65

II. Labile ............ 66

Eubbing; stroking 66

Passive movements 67

On inunction of the parts .......... 69

Clothing to be worn 71

CHAPTEE IV.

Active Movements.

Calisthenics and Swedish movement cure 74

Vlll

CONTENTS.

PAGE

Physiological effects of gymnastics • . 86

I. Circulation and heart 87

IL Skin and kidneys 89

III. Deposition of fat 89

IV. Kespiration . 90

V. Digestion . 90

VI. Central nervous system and mind 91

CHAPTEB V.

Diseases Suited to Mechano-thebapy.

Group I. Neuralgias and muscular rheumatism 100

Sciatica and neuralgia 104

Use of exercises other than those prescribed 128

Cases of sciatica 129

Suitability of mechano- therapy for recent cases 138

Cervico-brachialgia 141

General considerations 153

Cervico-occipital neuralgia 155

Trigeminal neuralgia 150

Intercostal neuralgia .160

Cephalalgia 161

Myalgia 164

Torticollis (stifl' neck) 170

Use of mechano-therapy during the occurrence of fever .... 170

Anaesthesia and hyperiesthesia 172

Arthritic neuroses 175

Palsies 179

Opium, morphine, and chloroform poisoning ...... 182

Chloral poisoning 185

Group H. Sprains 186

Synovitis, tendo-vaginitis, and glandular enlargements . . . 191

Serous tendo-vaginitisj chronic and crepitant 192

Mastitis and tonsillitis 193

Chronic metritis and parametritis 194

Stiffness of joints and tendons 204

Eye diseases 21(

Group III. Chlorosis, chronic catarrhal gastritis, phthisis, neurasthenia, ‘'
hysteria, hypochondriasis, and diabetes mellitus . . . .21-

Diabetes mellitus 23

Group IV. Cerebral congestion, haemorrhoids, and pulmonary emphysema 23
Group V. Chronic dyspepsia and constipation 23

(а) Exercises without apparatus . 24

(б) Exercises with apparatus 24

General Remarks 21

Group VI. Chorea and writer's cramp 2

MASSAGE AND METHODICAL MUSCLE EXERCISE.

II^^TKODUCTIO]N^.

HISTORY OF MECHANO-THERAPY.

The method of healing disease by mechanical means dates
back to the oldest literary records of the Hindoos and Chinese ;
the celebrated book of the Hindoos, the Sasruta, written long
before the Christian era, containing excellent descriptions of
medical gymnastics. The system was originally free from all
superstitious observances, but it soon became invested by the
Brahmins with various mysteries, of a kind calculated to
deceive the popular mind into a belief in its divine origin.
The priests thus not only increased their revenues, but, at the
same time, fostered the credulity of the common people in the
power of the remedy. The Brahmins continue, to the present
day, to use the same methods they did three thousand years
ago.

The oldest book of the Chinese, the Cong-Fou^ contains
detailed accounts of medical gj^mnastics, illustrated by draw-
ings which show what correct ideas on mechano-therapy this
ancient nation had.

In a book by F. Lutterbach, bearing the pompous title,
Mevolutim in the Art of Walking^ which appeared in Paris in
1850, we find most divers modes of respiration treated of ; yet
they were known to Chinese physicians centuries ago. The
title of the book Cong-Fou indicates its contents: *‘Cong”
meaning an art, “Fou ’’ a man ; therefore, “ the man who uses
an art [or perhaps the art used upon man ” ?].

According to recent researches, there can be no doubt that
it contains directions for treating, by gymnastics, sprains,
dislocations, and other similar surgical ailments.

INTRODUCTION.

According to P. Duhalde, there are in all provinces of the
Celestial Empire medico-gymnastic schools for the education
of physicians (who are called Tao-See\ at which hundreds of
patients congregate from all quarters of China to be treated.
One of the most celebrated of these establishments is in the
province of Kiang-Si, and the city of Kan-Tschean-Fou ranks
as the chief centre for the Tao-See, being the residence of their
grand master, who bears the title of Tien-See — i “celestial
physician.’’

In his work on The Chinese as They Are (London, 1841), Dr.
T. Lay tells of an ingenious and eftective means by which
Chinese physicians treat spinal curvatures. It consists in
the performance of certain definite muscle exercises, simul-
taneously with deep and prolonged inspirations ; in this way
the respiratory muscles are brought in to support those
lying along* the spinal column. Since time immemorial the
Chinese seem to have used gymnastic exercises to strengthen
muscles relaxed from over-fatigue, as also to remove cramps
and rheumatic pains. Instead of bleeding, as was formerly
the case with us, medical gymnastics were used by them for the
removal of a plethoric habit. Whether or no they based their
mechanical treatment on physiological grounds, or deduced it
from some therapeutic doctrine, we have no idea.

In an encyclopaedia, consisting of sixty-four volumes, which
appeared in the sixteenth century, under the title of San- Tsai-
Tou-Hoei, there is a collection of woodcuts representing ana-
tomical figures and gymnastic exercises.

With the Hindoos this ancient mechanical treatment goes
by the name of “ shampooing,” and in the Dutch Pacific
colonies it is called “ pidjet-ten,” and is in use as a domestic
remedy for the relief of pain in all the islands of the Indian*
Archipelago.

It is from the Hindoos and Chinese that a knowledge of
mechano-therapy seems to have been transmitted to the Greeks
and Romans, and the celebrated axiom of mens sana in corpore
sano^ comes to us from Democritus, a noted physician of Abdera.

Herodicos must be looked upon as the father of medico-
gymnastics with the Greeks. He lived a short time before the
Peloponnesian war, and was the first to lay down principles for

HISTORY OP MECHANO-THERAPY.

rational mechanical methods of treatment. He was also the
teacher of Hippocrates (born 460 B. C., on the island of Cos),
who first gave utterance to that saying, which is daily gaining
in appreciation : Natura sanat morbos ; naiura magister^ medicus
minister natures.

His directions for treatment are confined to a proper selec-
tion of diet, and to the observance of a suitable proportion
between exercise and rest. Hippocrates extended on a scien-
tific basis the principles laid down by his master, and his doc-
trines on bodily exercise were accepted by the most celebrated
physicians of Greece and Rome, such as Antilles, Orisabius
Asclepiades, Athenseus, Celsus, and Galen ; the latter teach-
ing nine different kinds of massage.

Plutarch tells how Caesar was cured of a general neuralgia,
by being manipulated daily by a slave. It was only in the
period of her decadence that Rome substituted the brutal
athletics of her barbarous circus sports, for the refined bodily
exercises introduced from Greece. The Christianity of the
Middle Ages resolutely turned its back on all Roman customs;
gymnastics, as practised in Rome, were banished, and mechano-
therapy thus sunk into the hands of quacks and ‘‘ bone-setters.”
In the year 1680, about the same time, therefore, that Bacon,
Descartes, and Newton gave those learned theories to the
world which have opened so many new pathways to the
science of medicine, Borelli published his work, De Motu
Animaliurriy which formed the foundation for the iatro-mechani-
cal school, opposed to the iatro-chemical, established by Para-
celsus.

The iatro-mechanists sought to explain all movements and
^functions of the body by mathematical and mechanical for-
mulas ; nevertheless, instead of seeking to cure disease by the
physical methods they established, they still had recourse to
the chemical agents of their opponents.

In 1740 there appeared an English work by Francis Fuller,
called Medical GymnastiquCj or Every Man his own Physicianj a
treatise on the infiuence of motion on the animal economy and
its importance in the cure of different diseases, as consumption,
dropsy, melancholy, etc. This book attracted much attention,
and went through several editions. It was translated into a

INTROD0OTIOK.

Qumbet of different languages, and gave rise to numerous special
worka, such as the Dissertatio de ark gymnasiica nam of von
Bdrner, and the De gymmticm imdicce veteris inventmbus of von
Ctehricke, both of which appeared in Helmstadt in 1748. But
at that time the medical world was too much occupied with
pharmaceutical and chemical speculations to give much atten-
tion to the kinetic methods of the ancient Greeks and of the
Tao-See.

In 1781, forty-one years after the appearance of Fulleris
book, a French physician, Clement Joseph Tissot, published a
work bearing the title Gymnastique midicale ou Vexercice appliqai
aux organes de Vhomme d^aprSs U lots de la physiologk de VhygUne
et de la thirapeutique. While both the English and the French
work show but little knowledge of true medical gymnastics,
they give proof of the high importance attached to the effects
of regular and methodic exercise on the living organism. Far
more thorough treatises on this subject were produced by
Barthez and the brothers Weber. In 1794 John Pugh's
Ireatise on the Science of Muscular Action appeared, and in 1808,
in Edinburgh, Dr. John Barclay’s work, which deserves espe-
cial commendation, entitled The Muscular Moiims of the Human
Body. He records a case of severe rheumatic muscle con-
tracture, which, after resisting all treatment, was finally cured
by simply percussing the affected sterno-cleido-mastoid. Never-
theless, although cases cured by medical gymnastics gradually
became known, but little attention was paid to the subject.
The works on the different branches of kinesipathy multiplied
notwithstanding. Among these may be mentioned Illustra-
tions of the Power of Compression and Percussion in the Cure of
RheumatisMy Gout^ and Debility of the Extrewdies^ and in Pro-
moting Health and Longevity, by Balfour, Edinburgh, 1819; and*
MMode nouvelle pour le traitement des dSviations de la colonne ver-
iSbrak, by Pravaz, Paris, 1827.

A marked progress in mechano-therapy was attained by M.
Blache when his paper, Bu traitement de la chorie par la gymnas-
tique, was read before the Academic de Medecine, in 1865. In
this he showed that mechanical methods not only equalled in
eflSciency those generally used, but were also free from many
of the disadvantages of the latter (see the chapter on Chorea ").

HISTORY OF MEOHANO-THKBAPT.

The most powerful impetus, however, given to the revival
of mechano-therapy origyiated with a Swede, the creator of
the modern ** movement-cure,” whose doctrines, spreading to
England and to Germany, have after many decades, and in
spite of being marked by some extravagancies, gained uni-
versal recognition.

The biography of this man only confirms the old experience
that, as a rule, all new ideas force their way but slowly ; and
that their originators have often to struggle against old and
firmly rooted views; that they are often, without fkir trial,
held up to ridicule as the product of a too fervid imagination,
to be laughed at, criticised, and condemned.

Peter Henry Ling was born in 1776, in Ljnnga Smaland,
Sweden, and attended, in 1804, the University of Copenhagen,
where he frequented the fencing academy established there at
the beginning of this century by two French ‘‘6migr6s.”
Having been cured of a rheumatic trouble in his arm by fenc-
ing, the thought struck him that systematic bodily exercise
might exert a favorable influence generally on the human
body and mind. Little by little he evolved the idea that the
harmonious development of the various parts of the body
should form an integral element in a national education, and
with persistent endurance he labored to make this idea a
reality. At that time there was at the military academy of
Copenhagen a gymnasium under the direction of an excelle%t
teacher of the name of Hachtigall, who was endeavoring to
reduce gymnastics to their true principles. In these efforts
he found a ready supporter in Ling, who eagerly studied those
remnants of knowledge of gymnastics found in the medical
works of the ancient Greeks. Finally, in 1806, Ling was ap-
Y>ointed fencing master to the University of Lund, and he at
once went to work to give a practical outlet to his aspirations.
He soon found, however, that he lacked the information most
necessary to attain perfect results, namely, a knowledge of
anatomy, physiology, and other natural sciences, and he, there-
fore, applied himself to master these studies.

In order to give some idea of his general attainments, it
may be mentioned that he was elected a member of the

INTBODUOTIOK.

Swedish Academy ip recognition of some historical and
poetical productions.

. For many years, however, Ling was forced to struggle
against ignorance and prejudice. When, in 1812, he applied
to the Minister of Education of Sweden for government sup-
port to push his endeavors, he was met with the reply : There
are already plenty of acrobats and rope-dancers without main-
taining more at State expense.” This answer, though dis-
heartening, did not discourage Ling, and he was finally so suc-
cessful in his endeavors that in 1813 the “ Central Institute of
Gymnastics” was established in Stockholm by royal decree.
Here Ling was enabled to perfect and propagate his methods,
and in a short time they were introduced, not only into all
public schools, but into orphan and insane asjdums, several
hospitals, and into the army. At the same time his lectures,
held at the Institute, were thronged as well by men of every
age and occupation, who came to learn, as by the sick, who
came to be cured at bis hands.

At first, the medical profession gave the new idea but little
encouragement, but they were forced to recognize its merits
on actually beholding the cure of numerous ailments which
had before resisted all forms of treatment. Finally, many phy-
sicians became zealous disciples and propagators of the new
doctrine.

^Meanwhile, Ling steadily rose in honor and esteem. The
King gave him the title of Professor, and created him a Knight
of the Order of the North Star. But he was not destined long
to enjoy the fruits of his indomitable energy, for consump-
tion, whose progress he had by his own methods stayed for a
while, put an end to his career in 1839, in the sixty-second
year of his age. The prime idea of his life was not forgotten'
even in his last hours, and on his deathbed he recommended
the gymnasium he had founded to the patronage of the King
and the support of th^ State.

During his busy life he had occupied himself exclusively in
putting his observations upon a broad experimental basis, and
in trying to deduce their fundamental laws; but ho did not
find time to formulate his doctrines. His larger work, A
Treatise on the General Principles of Gymnastics^ at which he

THE LIHO METHOD. 28

worked from 1884 till the time of his death, was, by his own
orders, completed by two of his pupils. Dr. Liedbeck and
Qeorgii, who had directed the Institute during his illness.
Massmann has translated the work into German.

After Ling’s death the direction of the Institute was under-
taken by Branting. The building in which it is situated
contains spacious halls for gymnastic exercises and rooms for
lectures, in which the following branches are taught : descrip-
tive anatomy, including dissecting; physiological anatomy so
far as it relates to the movements of the body; the principles
and theory of gymnastics; gymnastics with and without
apparatus; medical gymnastics; and, in addition, fencing
exercises of all kinds. The educational staft* consists of a
director, a sub-director, three professors, and eight tutors
(docents). Three hundred fencing masters are graduated
annually, besides several hundred chronic sick being treated
for their diseases.

THE LING METHOD.

Among thr Greeks the harmonious development of all the
organs of the human body formed the foundation of education,
not only of the youth alone but of the nation at large. This
sentiment pervaded their works on philosophy, and is found
practically embodied in all their laws; and was besides put
into actual practice in all institutions of learning, and at the
public games. It was placed under the protection of Apollo,
who, according to Plutarch, bestows health and intellect on
mankind by favoring the development of the body and the
harmonious production of strength.

Ling recognized the fact that the nourishment and develop-
ment of the muscles depended on the amount of active move-
ment they performed.

N. Dally affirms that Ling was probably acquainted with the
report of Pfere Araiot, or some other Chinese treatise, which
had reached him through missionaries, or through persons con-
nected with the European embassies in China, and that his
teachings, in theory as well as practice, are nothing more than
exact reproductions from the Cong-Fou and the Tao-See, Ling’s

INTRODUCTION.

biographer and pupil, Georgii, says : “ The genius and powers
of observation of Ling constantly afforded him new means
whenever he felt their need. The ingenuity with which he
devised new forms of movement to meet each indication may
be looked upon as a kind of compensation for the imperfect
physiological and biological knowledge which existed at that
time. He left to his pupils such manifold and numerous direc-
tions for movements that it has required years to study, to
explain, and finally to incorporate them into the science of
physiology and therapeutics.^^ And yet, according to Dally,
all his directions are contained in the Cong-Fou!

It might be well to remark that the idea of curing by
movement had been broached by Mercuriali as early as the
middle of the sixteenth, and by Hoffmann in the middle of the
eighteenth century, but without leading to further adoption.
Their methods sank into oblivion, just as the movement cures
of the Greeks and Eomans had done before them. Jerome
Mercuriali, of Verona, according to Daremberg,^ spent seven
years of his life in collecting from the manuscripts of the
Vatican everything pertaining to gj^mnastics, and in 1569 he
published at Venice the first edition of his work De Arte Gym-
nasiica. Unfortunately, Mercuriali does not seem to have
caught the spirit of the ancients. He evidently did not quite
understand what was meant by “ gymnastic exercise.’’ It is
true he recounts their method of dividing movements into
active, passive, and combined, but he drew no conclusions from
his knowledge. The errors he made were repeated by others,
without investigating and testing anew, and thus it was the
new science made no progress.

From the study of the ancients there arose in medicine three
new systems: that of Stahl, called the iatro-mechanical ; that*
of Boerhaave, the iatro-dynaraical ; and that of Friedrich Hoff-
mann, the mechano-dynamical. In all these three systems
some form of motion played the principal part in the bodily
functions, and from this idea the modern biological view of
medicine has been developed. All the more modern systems
of medicine recognize, so far as physiology, pathology, and

^ Dftreinberg ; Easal lur la determination et lea caracteres des periodes de rhiatoire de la medecine.
1PMrls,1850.

THB LING METHOD. 26

therapeutics go, the effects of motion on psychical education,
preservation of health, and the cure of disease.

It is in the mechano-dynamic doctrine of Friedrich Hoff-
mann that the first attempts at therapeutic gymnastics of the
German school are to be found, and as Hoffmann’s is a name
in the history of medicine too interesting to be passed over
without a word, the following brief sketch of him is given.

He was born in 1660, in Halle, in Saxony ; was made pro-
fessor in the university there in 1694 ; and for forty-eight years
lectured on medicine. He was equally renowned both as a
practitioner and as an author. Perhaps the highest praise he
ever won was from Boerhaave, who, when consulted profes-
sionally by the then reigning king of Prussia, Frederick Wil-
liam I., said, Your Majesty, my best advice is this: consult
Hoffmann.”

The underlying principle found in all of Hoffmann’s writ-
ings (collected in his great work, Medicim rationalis systematica)
he formulates thus : “ The human body, like all other bodies
in nature, possesses material forces, by means of which it
effects its movements. All these forces may be reduced to
mechanical and mathematical principles. An imponderable,
but material agent, cether (the active moving force), animates
all tissues of the body, and presides over physical phenomena
in every domain of creation.” ,

He says, furthermore : “ The living organism exercises the
functions peculiar to itself in consequence of qualities inherent
to all animal matter, which qualities are animated by a motive
force emanating in the form of a certain peculiar material
which is secreted by the brain, and carried into the body, and
is under the regulation of a complicated organic apparatus.
This sether is the fundamental cause of all vital motion. It
animates every organ, the functions of the latter ceasing the
moment the vivifying aether is no longer conducted to them.
Sight and hearing are abolished when the nervous fluid is
withdrawn.”

According to Hoffmann, the nervous aethereal fluid is
nothing else than the sentient soul presiding over organic life
and conditioning the very existence of man.

Again, he says : “ Medicine will never progress until we

26 . JNTBODUCTION.

closely examine the nature of this form of motion originating
in the sentient soul, and until we apply to medicine the laws of
mechanics and hydraulics.’’

In Hoffmann’s therapeutics the chief parts are played by
bodily exercise and rest, diet, and cold water, and by the observ-
ance of the simple laws of health. The sj^stem, it is true, con-
tains errors and imperfections such as were peculiar to his
time, but his principles stand as firm to-day as ever, and will
always remain as pillars of strength to the science of medicine,
It was he who first said to the scientific world : the human
body is but a machine, and subject to mechanical laws. He
then knew what was taught a hundred years later by the
Swedish school, that pressure on the phrenic nerve in the
neck would relieve a cramp of the diaphragm. He was the
founder of our modern school of medicine, whose constant
aim is to return to simplicity.

In his writings, Dissertaiiones physico-medicce^ 1708, the sixth
division of the first volume bears the superscription, “ Motion
the best means of cure for the body;” and in the first chapter,
‘‘On the attainment of long life,” he quotes the saying of
Celsus, “ The best of all medicines is — none.”

When we consider that Hoffmann wrote his celebrated work
at the beginning of the last century we cannot enough admire
the illumined n^ind which shows itself throughout his writings.
The preface to the work cited might have been written by
Skoda himself, and such clearness, moderation, and love of
truth are displayed in it that it merits a reproduction here.

He says : “He who carefully observes and tests Nature’s art
of healing, is forced to th*e conclusion that the basis of all
health, life, and disease is an exceedingly simple one, which
never changes, and is never confused. It is a matter of sur- •
prise, therefore, that physicians have invented so many means
of cure to preserve health and to combat disease. Nature
maintains life by simple processes. A few contrivances serve
her for the preservation of health, nor are the causes of disease
many. It is justifiable, therefore, to assume that the remedies
to be used in restoring health should be neitheV complicated
nor numerous. Indeed, we may not only assume, but I most
positively aflirm (and it may be put down to the misfortune or

THE LINO METHOD.

abuse of therapeutics), that the mass of medicaments and
elixirs found in the works of both ancient and modern phy-
sicians have had no other purpose than to impede the art of
healing, and to make it uncertain and deceptive. Certainly
the medicines by means of which the physician can support
the eftbrts of nature, achieve success, cure the sick, and win
honor for himself, are by no means numerous. There are
many things which, though they appear to have little influ-
ence in the healing of disease, or the preservation of health,
yet possess unthought-of power. Of this kind are those six
matters called the non-natural,^ whose intelligent application
may be of the greatest service in the art of healing without
medicaments. We have an example of their power in the
influence of movement and in the exercise of the limbs. The
influence of exercise is so strong — if we can believe the testi-
mony of the ancients and our own experience — that where
disease is to be prevented or cured it is to be prized more than
the most costly medicaments.”

“ I undertake the following work,” Hoffmann continues, “ in
order, with the help of God, to sift this question thoroughly,
and to determine as clearly as I may, what are the useful and
what the harm/ul influences of exercise, and in what way they
are capable of promoting health or checking disease.”

But to return to Ling. If we ask wherein his peculiar merit
lay, we find that he reestablished the gymnastics of the ancients
on a scientific basis, and using the then known results of
skilled German gymnasts, penetrated still deeper into the
writings of ancient nations, and became one of the first to
elaborate a complete system on an anatomical and physiological
basis.

In gymnastics, like in art, various schools have arisen, such
as the Swedish, the German, and the English. All these, by
various means, strive to achieve the same end, and as no branch

1 Before the modern discoveries in anatomy, physiology, and pathology, three kinds of matters
were recognized in regard to the human body : the natural, the non-natural, and the contra-natural.
Of natural matters there were stx-i. the tempt*ramentf«, the Immors (chyle, blood, lymph, bile,
urine, and feces), the vital and animal spirits (nervous fluid and eetlior), the solid and fluid substances,
the functions of organic and auimal life, and the elements (earth, air. Are, and water). Of non-
natural there u'ere likewise six : air, food, motion and rest, slee])ing and waking, the passions, and
those BulMBtances retained or excreted by the body. In the contra-natural were included disease,
with its causes and symptoms.

INTRODUCTION.

of science recognizes an end to its possible advance, in medico-
gymnastics, also, new methods are constantly being developed.
The pupils of Ling and their disciples spread the new doctrine
and methods through Germany, England, France, and Russia.
By the middle of this century already we find gymnasial insti-
tutions presided over by skilled instructors, scattered through-
out all these countries, and from this period, too, date a number
of the larger works on kinesitherapy.

In Sweden there were Branting, Georgii, and Sonden; in
London, Indebeten, Bishop, and Roth (an Austrian by birth);
in Germany, Rothstein, ifeumann, Eulenburg, E. H. Richter,
Koch, Hartwig, Berend, A. M. Bbttcher, and others; in
France, Becquerel, See Blache, Hervieux, Piorry, Dally, Laisne,
and others.

In Austria (Vienna) there was at that time but a single
individual who interested himself in the subject. This was
Dr. Melicher, who had studied with Branting in Stockholm,
and with Georgii in London.

Although the extravagancies indulged in by some of Ling^s
pupils may have brought upon the new system some discredit,
still they could not affect its lasting principles. Such eccen-
tricities as are found in Neumann’s work, The Therapeutic
Limits of the Movement Cure^ in which he aflirms that even such
tenacious hereditary diseases as carcinoma and phthisis may
be removed, simply deserve the silent disregard of the scientific
world.

Ling and his pupils devoted themselves chiefly to active and
passive movements. Mechanical manipulations such as were
first employed in France, between 1850 and 1860, under the
name of “ massage,” were but little used by them. The French
literature of that time on the subject is chiefly concerned with ‘
the mechanical treatment of ecchymoses, contusions, and dis-
locations ; and the works of Elleaume, Rizet, Magne, Lebatard,
Quesnois, Servier, and Millet have contributed more to the
surgical than to the medical aspect of mechano-therapy.
Nevertheless the work of EstradJjre (1863) must be looked
upon as marking an epoch in our knowledge of this subject.
He presented it as a thesis for the degree of doctor of medicine,
and it may be credited with the honor of having been the

THE LING METHOD.

model for a number of later publications. It is rather singular,
however, that this excellent work, so often quoted, is scarcely
to be found outside of the libraries of French medical institu-
tions.

Up to 1870, the literature of mechano-therapy was represented
by only a few large works or magazine articles ; this arose
from its practical application throughout the w’^hole of Europe,
with the exception of Sweden, being limited to a few specialists.

The results, often bordering on the miraculous, obtained by
these specialists, however, particularly in surgical cases, soon
attracted the attention of men eminent in the profession. An
interest began to be felt in “ massage in the diflFerent German
surgical clinics, and pains were taken to determine its indica-
tions and to develop its methods, and the success attained
naturally contributed largely to extend the new system.
Nevertheless, there was still considerable tendency to ascribe
the cures, especially in cases which had been considered
incurable, to some obscure or ill-understood influence, or to
chance, self-deception, or even to fraud. As recently as 1875,
Billroth published an article in which, while acknowledging
the successes obtained in his clinic by massage, he yet expressed
his doubts whether neurosal arthropathies could be successfully
dealt with by mechanical means.

The literature on the subject had, until then, consisted chiefly
of recorded observations confirmatory of statements previously
made by others, and was made up of either discussions of cures
of single cases, or explanations of general methods, in which,
however, ih^jurare in verba magistri became the universal rule.
Still, each of these publications had the merit of helping to
introduce the knowledge of mechano-therapy to the medical
public at large.

The first treatise on mechanical manipulations, physiologi-
cally considered, appeared in 1876, in Langenbeck's Archiv fur
klinische Ohirurgie^ and was the work of von Mosengeil, who
described some very instructive experiments made by him on
rabbits. It was through this work that mechano-therapy
emerged from the obscure mists of empiricism to step out
into the sunny fields of scientific research.

INTSODUCTION.

The total number of magazine articles and pamphlets from
all sources up to 1874, amounted to from one to four a year. In
1875 there were five ; in 1879 as many as nineteen publications
in various languages appeared. This noticeable increase shows
what a general interest in the subject was being taken by the
profession, whilst its adoption in the principal European clinics
gave it a scientific standing. Its popular appreciation, as well
as a recognition of its aims and its accomplished successes,
was shown by the erection of institutions for sanitary gym-
nastics in all the larger cities, and its introduction into all the
then existing hydropathic establishments.

During the past few decades it has gained an established
place in all works on general therapeutics (as in Rossbach’s
The Physical Methods of Healing, and the article by Busch in
Zkmsen’s Handbook^). In future, no treatise on ophthalmology,
gynecology, neurology, or on digestive or circulatory disturb-
ances, will be without a chapter on its appropriate form of
massage.

It is a curious fact in the history of sanitary gymnastics, that
while in Sweden, Germany, Austria, Russia, England, and
America, many eminent scientists are seeking to further its
progress by both word and deed, in France, where, twenty
years ago, so much activity was displayed in this field, and so
many valuable ideas brought to light, at present it is the
exception either for a clinician to prescribe mechano-therapy,
or for any physician of scientific attainments to busy himself
with it. Indeed, the very term “ massage ” is in bad odor, it
being associated in the public mind with a suspicion of
quackery. It is not that the potent efiects of the movement-
cure are unrecognized in France, but it lies, unfortunately,
at present, under the ban of public opinion, which will require
all the magic of some great and recognized scientific authority
to dispel.

I Ziemasen's Handbook of General Therapeutics. General Ortbopiedics, Gymnastics, and Mosnge.
By F. Busch. Translated by Noble Smith. New York, William Wood A Co.

CHAPTEK I.

Definition of the word “massage.” Reasons why mechano-therapy has not
become the common property of the profession. Can massage be learnt
without a teacher? To what extent can the general practitioner busy
himself with massage, and how much must bo left to the specialist? Can
laymen be employed as mechano-therapists ? Can the human hand bo sub-
stituted by apparatus ? Conclusions.

DEFINITION OF THE WORD “MASSAGE.”

The word massage^ derived from the French masser^ to knead,
literally means, a kneading. Yet kneading is only one of
the many manipulations used ; and there are diseases in which
— to adopt the popular term — massage is used without any
real kneading whatever taking place. Kneading presup-
poses the fingers actually pressed into the part manipu-
lated. This occurs whenever soft tissues, as muscles, are
manipulated ; but where treatment involves some bony resistent
part, as in frontal or supramaxillary neuralgia for instance,
kneading is out of the question. Here we can only speak of
stroking, or, at most, of stroking accompanied by pressure.
When a sprained and swollen ankle is subjected to “ massage,’^
there can, of course, be no question of true kneading, for it
would be next to impossible to press the fingers into the tense
and distended tissues. Here, too, the expression stroking com-
bined with firm pressure would best convey our meaning.
JThe process known as “ fulling ” ^ will give a good idea of
this manipulation.

In treating diseases like sciatica, brachial neuralgia, torti-
collis, chorea, and muscular rheumatism, not only are all forms
of massage brought into use, but passive and active movements
play an important — often the most prominent — ^part. Indeed,
without muscular exercises other than pure ‘‘ massage ” a cure
would hardly be possible in this class of cases.

1 A term iised by cloth-weavers to express a certain manipulation of the cloth accompanied by
rubbing.— Taamb.

32 ACCEPTANCE BY THE PROFESSION.

The term massage, therefore, by no means embraces all
that is included in mechanical therapeutics. Nor does the
term manipulations ihSrapeutiqueSy used by some French authors
ill place of the unpopular word “ massage,” entirely express
the method of treatment, for active muscle exercises cannot
be classed as manipulations.

To get around the word, Rossbach, in his excellent book on
the subject,^ has given to the chapter corresponding to mas-
sage” in other works, the heading “ Stroking and Kneading,”
but in his fourth paragraph he mentions tapping and beating
as among the principal manipulations of this method, and in
paragraph five, passive movements. His designation, therefore,
is likewise unsatisfactory. It would seem really desirable if a
better and more general designation could be united on. To
me, the term mechanical treatment seems to be all-comprehensive,
for active as well as passive exercises can be included under
it. The word “ movement-cure ” ^ used by Busch in his excel-
lent article on this subject in Ziemssen^s Handbook would be
very appropriate ; nevertheless, he chose for a title “ Gym-
nastics and Massage.”

WHY MECHANO-THERAPY HERETOFORE HAS NOT BECOME
COMMON PROPERTY OF THE PROFESSION.

The time was when reputable physicians scrupled to busy
themselves with mechanical treatment, or, if they did, hesitated
to commit to paper their ideas on the subject, or to contribute, by
clinical observations, their mite toward spreading this now no
longer new method of cure. That day happily is passed, and
mechano-therapy may be said to have received its formal
scientific consecration at the hands of such men as Billroth,*
Benedikt, Charcot, Eulenburg, Esmarch, Hervieux, Hiiter,
Gradenigo, Gussenbauer, Nussbaum, Pagenstecher, Piorry,
Trousseau, Winiwarter, and others, and to-day the most emi-
nent physicians do not for a moment hesitate personally to
treat disease by manipulations. The mechanical treatment of

I Lebrbacb der pbysikallBcben Heilmetboden, 11. Heft, Berlin, 1882.

s It is, perhaps, hardly necessary to note that this is the term most frequently used by English-
speaking authors. — ^TaaMS.

ACCEPTANCE BY THE PROFESSION. 88

a patient suffering from sciatica is certainly not more fatiguing
than operating for vesico-vaginal fistula, where the operator is
often constrained to remain from one to two hours in a most
tedious and uncomfortable position. It was formerly customary
to assert, with an aftectation of superiority, that it would hardly
be possible for a regular physician to condescend to use a means
until then only in vogue with quacks and female rubbers.”
But as quacks prescribe all sorts of medicines too, this objec-
tion can hardly be considered a valid one. Surely, the writing
of a prescription, which is but too apt to reveal small diag-
nostic acumen and even less knowledge of drugs, does not
require more intelligence than the mechanical treatment of
sciatica, which cannot be undertaken without a knowledge of
both anatomy and physiology. Prescription-writing often gets
to be a matter of routine, requiring in time but little exercise
of the intellect. The mechanical treatment of writer’s cramp,
chorea, or neuralgia, on the other hand, presents numerous
and interesting modifications, all of which have carefully to be
considered and which constantly present new incentives to the
inventive powers.

He who in mechano-therapy keeps only the mechanical part
in view, is cfn the wrong track. He must proceed like a
machinist, who constructs a machine on the basis of his knowl-
edge of mechanics and physics. In mechano-therapy, however,
as in most other fields, empiricism preceded scientific research.
Priessnitz, a peasant of Grafenberg, cured thousands by the
use of cold water, long before physiologists had demonstrated
the thermic and vasomotor effects of this simple means.
And it took many years before cold water attained a prominent
place among therapeutic measures, or even before the medical
•world became convinced of its powerful effects. Empirics also
have for centuries successfully used mechanical means in the
treatment of certain diseases, but only within a comparatively
short time have educated physicians deemed it worth their
while to investigate the matter and subject it to physiological
tests, divest it of all mystery, and reduce the cures to a scientific
basis.

When we consider that the literature of the subject has now
attained very respectable dimensions, and comprises excellent

H AOCMfANOB BT THE FEOFBSSION.

magaBiiie articles, admirable dissertations* and even volumin-
cos tomeS) and that, in spite of all this, mechano-therapy has
heretofore not become the common property of the medical
profession, we naturally ask ourselves, Why is this so ?

First of all, it is because every new idea forces its way but
slowly into acceptance. Mankind is prone to cling to what is
old and is, as a rule, too indolent to test novelties. Self-
interest, too, sometimes prevents our adopting a new form
of treatment, for as the physician cannot, even with the best
known remedies, promise a certain cure, the general public
would certainly be inclined to hold him culpable if he failed
when resorting to something novel and unusual. What diflS-
culties has not the country practitioner even yet to encounter
in applying the cold water treatment in typhoid fever, despite
the fact that since its introduction the mortality from this dis-
ease has, from being thirty-five per cent., sunk to eight per
cent.

One reason, probably, why mechano-therapy has not found a
more general introduction, is due to the absence of a thor-
oughly practical treatise on the subject, explaining the diiferent
manipulations, often difficult to describe, by numerous illus-
trations. To illustrate the importance of drawings, I will give
the following instance as an example;

In a recently published work, SchenkP says; “According to
Pageristecher, massage is performed by grasping the upper
or lower lid (according to the seat of the disease), with the
thumb near the edge, and rubbing it against the eyeball.’’

The interpretation of this paragraph might puzzle many
readers, and I am convinced that many physicians wishing to
employ this manipulation would not know how to go to work,
simply from being led astray by the word “grasp.” What*
Pagenstecher really meant to convey was that the lid should
be steadied with the thumb and then pressed against the eye-
ball. One cannot properly speak of “grasping” anything
with one finger; the idea presupposes the use of, at least, two
fingers, which hold the object grasped.

This drawing (Pig. 1), however, which Dr. Schenkl has

1 Bcbenkl : “ Becent Therapeutic llxperimeuts in Ophthalmology/* Prager med. Wochenschrift,
Ko. 80, 1882.

i.OOBPTAITOB BY THB PBOPBSSlOH. 8S'

kindly given nae permission to reproduce, at once clears up any
doubts as to how the fingers are to be used in this manipula-
tion, and any one can see, at a glance, what Pagenstecber
meant by the word grasp.”

Fig. 1.

^ Even where no faulty diction leads to error, it is often dif-
ficult to perform a certain manipulation from its description
alone, if it be not illustrated.

Perhaps another reason why mechano-therapy is not in more
common use lies in the fact that its methods cannot be learnt
without the expenditure of much time and trouble, and this
brings us to a question which we deem worthy of a more
extended discussion.

IS A TEAOHEB NECESSARY?

CAN MASSAGE BE LEARNT WITHOUT A TEACHER?

Until quite recently, it has been the custom to affirm that one
could only become a mechano-therapist by being instructed by
others. I may, however, claim for myself the small credit of
having been the first to show, in an address delivered before
the fifty-fourth meeting of Natural Scientists (Naturforscher-
Versammlung), held, in 1881, in Salzburg, that this opinion
is erroneous, and that the necessary knowledge and skill can
very well be mastered without an instructor, if, with each
manipulation, the final end, namely the physiological effect, be
kept strictly in view; w^hile, on the other hand, mere slavish
injitation of the description of some procedure, even when car-
ried out to its minutest details, wdll never lead to success.

Descriptions aiid explanations are, of course, indispensable,
but every practitioner of mechano-therapy deviates insensibly
and often considerably from the original directions; just as
an experienced surgeon, though following generally prescribed
rules, yet performs an operation in his own individual way.

Anyone devoting much time to mechano-therapy will fall
naturally into methods peculiar to himself. Given a particular
case, and different physicians, all, perhaps, equally skilled in
the art, will proceed each according to his own method, yet
the various means adopted will all attain the same end in view.
The beginning only is difficult, and confidence in the method
will at once be acquired by the cure of a single case; especially
of one before regarded as incurable. No mere routine must
ever be allowed to replace the application of those anatomical
and physiological principles which must be our guides in the
treatment of every case. ^

So far as self-teaching is concerned, almost involuntarily
the question occurs : IIow did the first practitioners of the
method begin? Who taught them? Certainly, only their
own endeavors. It follows, therefore, that any physician may
acquire the methods up to a certain degree of perfection,
merely by study and reflection. Nevertheless, special instruc-
tion, or often the simple observing of others, greatly facilitates
the progress of a beginner. Obstacles will be sooner overcome,

GENERAL PRACTITIONER AND SPECIALIST.

and doubts and diflSculties more easily removed, besides much
useless experimentation is saved. The fact also of being con-
stantly encouraged and stimulated in one’s task by the advice
of some experienced physician, is no small gain. ' In addition
to all instruction, however, a certain inborn mechanical dex-
terity is indispensable, and it is very evident that there are
numbers of physicians whose whole nature unfits them for
this kind of practice.

TO WHAT EXTENT CAN THE GENERAL PRACTITIONER
USE MASSAGE, AND HOW MUCH MUST BE
LEP"T TO THE SPECIALIST?

The determination of this question seems to me of consider-
able importance, for let it be once clearly settled and the
beginner will not only be saved many failures, but he will also
be prevented from unjustifiably condemning the whole system.
Every physician, in the smaller towns, at least, is obliged to
practise a certain amount of surgery, ophthalmology, laryn-
gology, otology, etc., yet in all cases requiring special expe-
rience and skdl he summons the aid of a specialist. He
should act in the same way in regard to mechano-therapeutics.
Every practitioner ought to be able to open an abscess, to
catheterize, to bleed, to reduce a fracture or a dislocation, to
treat a conjunctivitis, to make an application to the vocal
cords, or to introduce the Eustachian catheter; but, as a rule,
he w’ould hardly undertake to perform amputation of the
thigh, extract a cataract, extirpate a laryngeal polypus, or tre-
phine the mastoid process, even if for no other reason than the
impossibility of obtaining the necessary assistance for himself,
*or the care and nursing required for the patient.

In applying mechanical treatment similar conditions obtain.
After a little study and practice no physician should have
any trouble in treating a sprain, an acute muscular rheuma-
tism, or a mild brachial neuralgia, but he will hardly have
either the facilities, dexterity, patience, or time to treat a
sciatica of years’ standing, or writer’s cramp, or confirmed
constipation, or marked chorea. A specialist will, in all prob-
ability, be required for the treatment of this class of cases, A

LAYMEN AS MEOH ANO-THER APISTS.

specialist will not be discouraged by the apparent lack of suc-
cess in the beginning (often extending over months), and he has,
besides, apparatus which facilitates the cure, or may indeed
have an establishment at his disposal wherein trained assistants
devote all their time and energies to this subject alone.

It is often said that a busy practitioner has no time to give
to mechanical treatment. This is, however, a mistake. The
more difficult cases, requiring much time, he would, as it is,
recommend to specialists, but many of the milder cases do not
require as much time as attending a confinement case, dress-
ing a wound, making an ophthalmoscopic examination, or
applying a plaster splint; yet every physician is expected to
find time for all these things, and as often, too, as occasion
demands. To go still further, the mechanical treatment of
acute muscular rheumatism or of a recent neuralgia takes de-
cidedly less time than any other method, for while many days
and even weeks are often consumed trying all sorts of medi-
cines, a cure might have been effected in these cases by me-
chanical means at a single sitting.

It has sometimes been objected that the mechanical method
requires a degree of bodily strength such as every physician
cannot command. This assertion, however, needs to be quali-
fied. I admit that many manipulations require considerable
muscular power for their accomplishment, and especially a
steady hand, and in treating a dislocated ankle or an inveterate
neuralgia, many physicians might experience great fatigue.
Such physicians must necessarily give up the idea of becoming
mechano-therapists, but, so too, as we have seen, must he who
is, by lack of natural dexterity, unfitted for the task. Experi-
ence, however, has shown me that the strength of the manipu-
lator increases with practice, or, to put it another way, that the
experienced physician does not tire so soon, because in becom-
ing more expert he learns to husband his muscular power.

CAN PERSONS, NOT PHYSICIANS, BE EMPLOYED IN
MEGH ANO-THERAPY ?

Professor Schuh, the celebrated surgeon, had an orderly at
his clinic, of the name of Vasali, who secretly gave courses in
operative surgerv in which, it is said, he used to ligature all

THE HUMAN HAND SUPERIOB TO APPARATUS. 89

the large arteries with his eyes shut. Anton, the well-known
servant of the great Rokitansky, knew how to hold his own
on the significance of pathological appearances against many
a professor. I think these instances will be answer enough to
the above query. There can, indeed, be no doubt that an
intelligent layman can master the numerous manipulations
which are used in the mechanical treatment of disease. The
instances mentioned above need, perhaps, a few words of
explanation. Vasali had, in the course of twenty-five years,
seen thousands of operations at the clinic, and had attended
dozens of operative courses; and old Anton assisted at no less
than seventy thousand autopsies made by his great master.

Much experience and hard study should be required of a
layman before he is entrusted with the full treatment of a case.
The different manipulations are in themselves, not difficult to
learn, if only the necessary regard be paid to the relations
existing between bone and soft parts; but the active and pas-
sive movements so indispensable for the cure of certain forms
of disease require an exact knowledge of anatomy and physi-
ology for their proper performance. These, therefore, should
always be performed by the physician himself, or at least
under his direction and oversight.

CAN THE HUMAN HAND BE SUBSTITUTED BY APPARATUS?

Many devices have been invented for saving the manipu-
lator’s strength, such as Klemra’s muscle-beater, the elastic
rods with rubber balls of Graham, and the machines run by
steam of Zander. All these are well enough in their way for
treating certain phases of disease, but in general they may be
said to be wholly inadequate to our needs, and are quite apt to
degenerate into mere playthings. No better results can be ob-
tained than with the practised hand, which surpasses even the
best of instruments, and the skilled operator needs no other
aid, no matter what kind of manipulation he may wish to per-
form. In the fingers, the fist, the edge of the hand, and in
the forearm and arm, we have an armamentarium possessed of
the greatest variety of effects, for their use is capable of in-
finite multiplication by the variously graded force with which

CONCLUSIONS.

they may be employed. On the other hand, in executing pas-
sive and active muscle exercises, apparatus can be used to the
advantage of both patient and physician. Indeed, without it,
treatment would often be rendered far more difficult. Never-
theless, it is possible to dispense with special apparatus, and
hy employing instead, such household furniture as may be at
hand, still attain one’s end and effect a cure. The physician
will have frequently an opportunity to display on these occa-
sions his ingenuity and intelligence.

A detailed account of the apparatus used will be given in
the chapters on the treatment of the separate diseases.

CONCLUSIONS.

I think, from personal experience in the matter, I am justi-
fied in laying down the following:

1. Every physician having the inclination and ability, no
matter where he may practise, may acquire, self-taught, and
successfully employ the methods of mechano-therapy in the
treatment of disease.

2. The absence of apparatus such as is generally found in
regular establishments is no insurmountable obstacle to suc-
cess. It may, only render the application of the system a little
more difficult, and perhaps retard the cure somewhat.

3. Old and chronic cases, requiring special means, special
experience, and special treatment, are best referred to the
establishment of some specialist.

4. Laymen, by instruction, and by observing others, may
be trained to perform all the various manipulations, but allow-
ing them the independent treatment of a case is not always,
without danger to the patient.

CHAPTER II.

Physiological, primary, and secondary effects of mechanical interferences.
Evolution of heat in muscles as a result of mechanical concussion.

PHYSIOLOGICAL EFFECTS OF MECHANICAL INTERFEKENCES.

These may be divided into two groups :

1. Primary (purely mechanical) effects — L e., the removal of
lymph, exudations, transudations, and extravasations, the de-
struction of exudations by pressure, the removal of vegetations
by frictions, and the solution and removal of adhesions.

2. Secondary effects ; which act by increasing the circulation
by stimulating the muscular and nervous systems, by setting
up molecular changes, and producing consequent changes in
sensation, and by effecting alterations in the processes of gen-
eral nutrition.

1. Primary (purely Mechanical) Effects.

If any portion of the body be forcibly stroked in a centri-
petal direction, acceleration of the lymph and venous currents
occurs in the part. The reasons for this arise from the
anatomical arrangement of the lymphatics and veins. The
capillary lymphatics originate as stomata in the lymph-spaces
of the tissues. They have, besides, openings in their continuity
communicating with the lymphatic canaliculi. These openings
absorb from the tissues the lymph — which is nothing more
than the plasma of the blood after it has parted with its nour-
ishing ingredients to the tissues — and carry it to its ultimate
destination. A reflux of lymph toward the periphery is pre-
vented by valves similar to those in the veins. The accele-
rated flow of lymph in the part which has been pressed or
stroked has also a secondary effect, as it allows the mechani-
cally emptied vessels more readily to absorb the fluid newly

42 EFFECTS OF MECHANICAL INTERFERENCES

exuded from the capillaries. We see that stroking and pres-
sure, therefore, act like a pump to the venous and lymphatic
vessels. The reason that active or passive movements are
such valuable accessories to the different manipulations, arises
from the fact that by compression of the vessels muscular con-
tractility likewise hastens the lymph and blood current.^

There can be no doubt that exudations and transudations,
when accessible to mechanical treatment, may, by repeated
pressure, be finally disintegrated and liquefied, and in this state
forced into the lymphatics in the tissues. Even old exudations
of years standing and of firm consistency, are frequently re-
moved in this way. MosengeiPs^ exceedingly instructive ex-
periments have shown how rapidly and powerfully mechani-
cally induced resorptioii acts. He has expressed the belief
that the cellular elements detached by massage are absorbed —
consumed, as it were — and digested by analogous cells.

It is worth while to give here in detail one of his experiments :

At 9 A. M. he injected a hypodermic syringeful of India-ink
into both knee-joints of a rabbit. The temperature in the
rectum, immediately following the operation, was 100.8° F.
At 9.30 A. M. the right knee was manipulated, the rabbit
seeming unaffected by the operation, being quite lively and
running about. At 9.45 a. m. both knee-joints were again in-
jected with the same quantity as before, but with a less con-
centrated suspension of the ink, and the right knee was again
at once manipulated. The pain seemed more intense with
this injection than with the first; the rabbit resisted violently,
and was hard to hold. The manipulation of the joint, too,
seemed to be more painful. After manipulation, the knee, pre-
viously swollen, became of normal size again. It was noticed
that the left leg, which, as a check experiment, had not been
manipulated, was likewise less swollen after the rabbit had run
about a while. At 3 p. m. injections were again made into each
knee-joint, and the right knee manipulated as before. In two
minutes the swelling of the right knee bad disappeared, while
the tumefaction of the left remained permanent. In the mean-
while the temperature had risen to 102.2° F., and at 8.30 p. m.

1 Wundt: Lehrbuch des Pbysiologie des Meuschen. Erlangen, 1873.

* Von Mosengeil : Langenbeck's Archiv fUr klinische Ohirurgie, 1876, 9 Band, 3 and 4 Hefto.

PRIMARY EFFECTS.

reached 104° F. However, to judge from its hearty appetite,
the animal did not seem to feel very badly. At 8.45 p. m. the
knees were again injected. It was now found that a whole
syringeful could no longer be forced into the left knee, but
readily entered the right, which was again manipulated. On
the following morning half a syringeful of a thick suspension
of the ink was injected into each elbow-joint, both joints were
manipulated, and the animal then killed and examined. In
the upper extremities the ink was found distributed in irreg-
ular patches in the periarticular connective tissue about the
puncture, and extending into the subcutaneous tissue, and also
upward along the vessels and the intermuscular septa. The
axillary glands of one side were found to contain India-ink;
the lymphatics leading to them being intensely black. On the
other side, on which a colleague had performed the injection
and attempted the manipulations, no ink was found in either
lymphatic vessels or glands.

• In the lower extremities the condition of things was some-
what different, owing to the injections here not having been
made immediately preceding the animal’s death, but some
little time before.

We see from this interesting experiment that it is possible
within the space of a few minutes to remove a fluid injected
into the knee-joint of a rabbit, by manipulations which
force it into the lymphatics. It is true that von Mosengeil was
unable to actually demonstrate an endothelial lining in the
channels taken by the ink, but the mere fact that a certain
deflnite (course was in each case taken speaks strongly for their
preexistence.

Since the pain in an inflamed area is caused by the pressure
of some exudation upon sensory nerves, relief from pain will
follow in proportion to the removal of this pressure, and we
may, therefore, claim analgesia as one of the effects of mechano-
therapy. An antiphlogistic effect is also produced, inasmuch as
by manipulation the lymphatics are emptied, tumefaction dis-
appears, and with it heat and redness. By accelerating the
lymphatic and heemic circulation, accumulation of fluid may
be prevented ; or, if already present, may be removed. Thus
the power of causing resorption is another of its effects.

44: EFFECTS OF MECHANICAL INTERFERENCES

11. Secondary Effects of Mechanical Interferences.

The most important effects of mechano-tberapy correspond
to those produced by electrical or chemical stimuli on the vaso-
motor nerves and muscle fibres, namely, in the first instance
dilatation and contraction of the arterioles, and, in consequence,
increased absorption and nutrition; and, secondly, muscular
contraction.

Innervation of the bloodvessels occurs, as is well known, in
two ways. First, by parietal ganglionic centres; and, secondly,
by extrinsic nerves whose stimulation has a direct influence
on the lumen of the vessel.

If the efieets of mechanical interference on a vascular area
l)e studied microscopically in some transparent tissue, as the
mesentery or the interdigital web of a frog, it will be observed
that, as a rule, there is at first a contraction of the arterioles,
which at times amounts nearly to an obliteration of their
lumina. This contraction is often of very short duration, and
is succeeded by a dilatation lasting over a considerable period,
during which the current of blood is retarded in the whole
vascular area involved, but especially in the capillaries, so that
diapedesis of white and sometimes even of red blood globules
may be observed to occur.

According to Claude Bernard, this dilatation may begin im-
mediately upon the application of the stimulus. We infer,
therefore, from the phenomena observed, that the walls of the
vessels, like those of the heart, contain both an active motor
and an inhibitory nervous apparatus.

Besides reacting to direct stimuli, the vasomotor nerves
may be affected reflexly also through the sensory nerves.
As a rule, the vessels of parts whose sensory nerves have been
stimulated become dilated ; the vessels of the ear, for instance,
dilate after stimulation of the auricular nerve, and the vessels
of the foot, after stimulation of the dorsalis pedis. The local
distribution of blood is, therefore, constantly subject to change,
in consequence of the contraction and dilatation of the arteri-
oles resulting from either direct stimulation applied to the vaso-
motor nerves themselves, or indirectly to the sensory nerves;
and the function of any organ, as the act of secretion by glands,

SECONDABY EFFECTS.

or the state of contraction of a muscle, is always accompanied
by local hypersemia. Should this reflex vascular dilatation
become permanent, then the process changes to pathological
hypersemia and inflammation.

The increased temperature which is produced in the parts
subjected to mechano-therapy is of material benefit in cases
where, as a result of disease, diminished nourishment of the
tissues, and consequent diminished temperature, has occurred.
The cold bands and feet of chlorotic and anaemic patients are
instances of this. Of all the organs of the body the nerves
and muscles are most capable of being powerfully influenced
by mechanical interference. Mechanical stimulus produces in
them as well-recognized physiological eftects as do chemical,
thermic, and electric stimuli. In nerves (both sensory and
motor), as well as in muscles, mechanical stimulation arouses
a condition of excitation which, being transmitted by the
nerves to glands and muscles, finally becomes evident in the
phenomena of secretion and contraction.

The [central] nerve cells (ganglia of excitation) which are
interpolated in the course of the motor fibres either conduct
motor impulses uninterruptedly onward, or reflexly transfer
them to more pcj^ripherally situated parts. From this arrange-
ment the following combinations may arise :

1. The combination of one sensory fibre with another. The
result will be sensation stimulation.

2. Of sensory with motor fibres. Result : reflex movement.

3. Of sensory with secretory fibres. Result: reflex secretion.

4. Of sensory with inhibitory fibres. Result: inhibition of
muscular contractions or of secretion. (Inhibitory reflex.)

The mechanical stimulus bears more resemblance to the
electric than to any other; like it, the effects called forth are
proportionate to the intensity of the application. According
to Valleix, compression lessens neuralgic pain, and pressure
upon a muscle or nerve may, if gradually increased, be even
carried to a point where crushing of the tissues occurs, without
calling forth a contraction* On the other hand, a single sudden
application acting upon a motor nerve generally calls forth a
single contraction — tenanic contraction resulting only when a
condition of extreme irritability exists. When the mechanical

€$ BfrEGTS OF KACHAKIOAL INTSBFBBEKCSB.

fttimulua is applied with rapid intermissions to the same spot
OB a nerve, tenauoid contraction results.

Schiff has shown that mnscular tissue possesses a contractile
power independent of that supplied to it by the nerves, and
which persists even after death. Tliis contractility he has
called “ idio-muscular.’’ Its existence may be demonstrated
by striking a muscle with some blunt edge, perpendicularly to
the course of its fibres. A single blow upon a nerve produces
in it a heightened irritability which rapidly disappears again,
while more lasting alterations result when many blows rapidly
following one another, act through the causation of a cumula-
tive effect. The result of mechanical stimulation on nerves
and muscles depends no doubt, in many cases, on the initiation
of molecular changes in the elements of these tissues.

The effects of a blow upon the peripheral end of a (sensory)
nerve are conducted to the nerve centres, and thence trans-
ferred to a motor nerve. This propagation of a mechanical
stimulus can perhaps be explained by the formation of waves
in the nerves, upon the theory of Fleischel, that the axis-cylin-
der of the living nerve is fluid in consistence.

The hypothesis, too, that certain nervous affections are due
to molecular changes in the nerve elements finds some support
in the fact that favorable results are obtained by such surgical
procedures as exposing and stretching the nerve trunks, which
possibly set up certain other molecular changes in the nerves.
In mechano-therapy it is true the nerve trunks themselves
are not directly pulled and stretched, but their thousands of
terminal plates are subjected to every kind of mechanical
manipulation. The chemical changes constantly taking
place within the nerves may be looked upon as the outcome of
molecular work, and as the expression of continuous molecular
change.

When a mechanical stimulus operates upon a nerve it first
induces in the latter a certain amount of latent energy, which
being transferred to a muscle, there becomes manifest in the
shape of work. The stimulus, however, is not always thus
transformed, nor, when it is, need it occur at once.' For ner-
vous energy the result of molecular change, exists largely in a
latent state, only part of it being manifest.

SSCOKBAET EFFECTS.

Nervous energy is the result of chemical changes occurring
in the nerve tissues. And while of the energy so produced a
small fraction is again utilized in chemical action for the pur-
pose of reuniting the molecules necessarily disassociated, the
greater part becomes free, and manifests itself either as me-
chanical work or in the shape of heat. Speaking generally,
we may say that nervous irritability is any form of external
energy, producing either temporary or permanent molecular
disarrangement of the nerve elements.

Any source of energy conveyed to a nerve from without first ex-
pends itself in producing molecular change^ and this is again con--
verted into energy manifesting itself through the various forms of
innervation.

This physiological theorem is of great importance for the
proper understanding of the effects of mechano-therapy, and in
the treatment of neuralgias it finds practical application.

The nature of the translation of molecular change into
nervous energy has, so far, not been discovered. It may pos-
sibly be that the external (mechanical) stimulus increases mole-
cular change, and that this causes at the seat of stimulation a
greater disassociation of chemical molecules than would perhaps
otherwise take plrce.

This translation into nerve energy proceeds somewhat on
the principle of an explosion, in which, before the final out-
break occurs, there is a gradual accumulation of effecting
causes. The recent experiments of Tigerstedt^ indicate that
the active energy of the stimulus is converted into a form of
motion peculiar to the nerve substance; but exactly how this
conversion takes place, and how it is that the most various
stimuli all produce the same form of motion, are questions
y*et unsolved. Tigerstedt concludes that the normal functional
activity of the nervous system consists of a species of wave-
motion — thus coinciding with Hallstein, Wundt, Fechner, and
Heidenhain.

For an intelligent comprehension of the means by which
mechanical interferences act upon nerves and muscles, it will
be necessary to glance for a moment at the most important

^ B. Tigerstedt : Studien Ubcr meohanische Norvenreizung. Helsingfors, 1880.

48 EFFECTS OF MECHANICAL INTERFERENCES.

physiological facts regarding the chemical changes occurring
during nervous and muscular activity. We know but little
about the metabolism of nerve-tissue, whether it be quiescent
or active. That of the muscle, on the other hand, has been
pretty thoroughly studied. According to DuBois-Reymond,
the most prominent change occurring in the muscles in conse-
quence of their functional activity, consists in the production
of a free acid — probably lactic — and the acidity is proportional
to the amount of muscular exertion. Other things being
equal, also, it is greatest when the muscle, still stimulated to
action, is prevented from contracting by a load. In the chapter
on “ Swedish Health-gymnastics ” we shall again have occasion
to refer to this fact.

In connection with the formation of acid, there is probably
a simultaneous destruction of the carbohydrates, especially of
the glycogen (Nasse and Weiss).

The proportion of fat, water, kreatin, and extractives in-
creases, according to Sarokin and Ranke, while the nitrogenous
bodies diminish somewhat in quantity, the changes being
influenced by the respiration of the muscles. The experiments
of Herrman, Ludwig, and Sczelkow show that an active
muscle consumes more oxygen and produces more carbonic
acid than a passive one.

According to A. Schmidt, the muscle while active produces
also a larger number of readily oxidizable substances than
when at rest. Still other experiments have shown that in the
formation of carbonic acid in muscle besides direct oxidation,
there occurs a splitting up of various substances containing
oxygen in order to furnish the necessary amount of oxygen
required. The increase in the consumption of oxygen and in
the production of carbonic acid in the active muscle is, to*a
great degree, determined by the rapidity of its blood current,
for Ludwig observed when he increased the rapidity of a
current of warm defibrinated blood, conducted through an
extirpated mammalian muscle retaining all its functional
powers, an increased interchange of gases took place, even
when the muscle was quiescent. An intimate connection
probably exists between the fatigue of a muscle and the
chemical changes taking place within it, for an intravascular

GENERATION OF HEAT IN MUSCLE. 49

injection of lactic acid or of the acid potassium phosphate
increases the fatigue of a muscle so treated. The revivifying
influence of the blood current, therefore, acts not merely by
carrying fresh materials, especially oxygen, for consumption,
but by removing the eflfete products of combustion. For the
nerves, according to Ranke, similar conditions obtain.

We see, therefore, what a marked eflfect the accelerated
blood current, such as mechanical treatment produces, may
have upon the chemical processes occurring in muscle- and
nerve-tissue. Mechanical interferences also act reflexly through
the cutaneous nerves. Thus, for instance, friction of the
abdomen acts upon the hypogastric and solar plexuses, and,
through them, upon the organs of circulation and digestion,
which they control, stimulating the involuntary muscles of the
stomach and intestine, and inducing uterine contractions.

It is a well-known physiological fact that heat is generated
in muscle during contraction. Indeed, numerous experiments
have shown that most of the combustion going on in the
body occurs in the muscles. A muscle, even in quiescence,
deprives the blood of its free oxygen, or rather of that existing
in loose combination with the haemoglobin. In a condition of
activity this consumption of oxygen becomes increased five-
fold. That mere mechanical vibration of a muscle is alone
capable of generating heat, has been recently proved by the
interesting experiments of Danilewsky. I think it worth while
to insert here a short account of them, taken from Fick’s^
work, being convinced that it will form a valuable contribution
to the practical aim of this book.

GENERATION OF HEAT IN MUSCLE DURING MECHANICAL

VIBRATION.

Danilewsky made experiments to determine the rise of
temperature experienced by a muscle when torn and vibrated
by a falling weight.

He first experimented on inanimate objects. His apparatus
consisted of two thin rubber plates connected by clamps to an
elastic band. Between the two plates a thermo-electric pile

1 rick ; Mechaniache Arbeit und Wiirmeentwicklung bei der Muskelthiitigkeit. Leipzig, 1882.

GBNEEATION OF HEAT IN MUSCLE.

was introduced ; then, by means of a lever a weight was allowed
to fell upon the rubber plates, throwing them into vibrations.
The needle of the galvanometer was deviated, and a calcula-
tion showed an increase in the temperature of the rubber
plates amounting to 0.0016° C.

This method he next applied to the living muscle of the frog,
the thermo-electric pile being introduced between two muscles
hanging parallel, side by side. Here too an increase of tem-
perature after causing vibration of the muscle elements was
demonstrated.

CHAPTER III.

Description of the mechanical interferences used. Stabile interferences :
tapping; thrusting; hacking; Kleram's muscle-beater ; pinching ; squeez-
ing. Continuous interferences: rubbing; stroking. Passive movements.
Should the parts to bo treated be previously oiled ? Is treatment to be
undertaken upon the naked or clothed body ?

DESCRIPTION OF THE MECHANICAL INTERFERENCES USED.

The number of different manipulations which have been
used in mechano-therapy is exceedingly great, certain authors
seeming to find pleasure in giving special names to each small
modification of the principal manipulations used. Thus one
reads of constricting, pulling, pressing, hacking, kneading,
rubbing, stroking, tapping, sawing, squeezing, stretching, con-
cussing, pinching, sticking, etc.

Estrad^re described no less than five varieties of tapping
alone (hachures, claequemmts, vibrations pointSes, vibrations pro-
fondes^ and la palette). But this elaboration and multiplication
of subdivisions, which, by some authors, is carried even to a
greater excess, is to be condemned as tending to discourage
the beginner. Rossbach, in his treatise^ on the subject, vigor-
ously contests this useless differentiation in the chapter on
“ Stroking and Kneading.^^ He says : In the physiological
division we have seen that it is merely a question of the pro-
pulsion of blood, lymph, .and exudations from the periphery
toward the centre, and certainly the processes of stroking,
rubbing, kneading, and tapping will suffice to attain every-
thing that can be obtained at all by this system. The urgent
appeal to ‘please to keep your inventions to yourselves,’ may,
therefore, with propriety be directed to all those ingenious
inventors of trivial subdivisions.” Everyone who has devoted
any time to mechano-therapy will gladly subscribe to Ross-

^ Lehrbuch der physikaliscben Heilmetboden, p. 492.

MECHANICAL INTERFERENCES USED.

bach’s sentiments. I must, however, take exception to the
remark that it is a question of the removal of exudations,
blood, and lymph alone. In many diseases of the muscular
and nervous systems it is of prime importance also to produce
vibrations and to cause an evolution of heat — in other words,
to bring about molecular changes in the primitive elements of
the tissues in question.

While the complicated and circumstantial description of
methods employed by some authors is a serious hindrance to
the popularizing of mechano-therapy, still the manipulations
required for the production of these molecular changes cannot
all be embraced in the terms “kneading,’’ “tapping,” or
“ beating.”

The various procedures cannot be too simply stated, how-
ever, for the beginner. I am convinced that any physician
having the inclination and aptitude for this form of thera-
peutics will be able to invent for himself such minor modifica-
tions as are needed in the course of treatment, from the
anatomical conditions, or from individual peculiarities, while
descriptions and explanations which descend to trivialities
will, at best, be of little use to anyone lacking the necessary
natural qualifications for the work.

Before going on to a description of the different manipula-
tions, I think it but right to mention that mechano-therapy, in
its execution as well as aims, is a very different thing from
that generally described as “ hygienic massage.” It has nothing
in common either with those practices of. the Greeks and
Romans, which formed such an integral part of their baths and
which aimed at the production of feelings of sensuality or of
delicious ease, or with the manipulations used in the baths of
the Orient, and now in general use throughout Europe, which
simply afford for the bather a pleasant way of passing the
time.

Savary,‘ in his letters from Egypt, in describing a bath
taken by him there, speaks of the delightful feelings produced
by passing through a series of apartments of graded tempera-
tures, of being surrounded by scented vapors, of having his

1 Extract from the letters of Savary on the baths of Cairo, in Ph61jppeaux*s Etude pratique sur
les frictions et le massage. Paris, 1870.

CLASSIFICATION OF MECHANICAL INTBBFEBBNCES. 68^"

body scoured, pressed, and kneaded, and his limbs stretched,
and his joints cracked, of being enveloped in clean linen, laid
upon a soft couch, and having all parts of his body dried by
the tender hands of children. When, finally, he mentions
the coffee and tobacco which contribute to the pleasure of
the massage, when he breaks forth in hymns of praise on the
delicious feeling of sensuous ease produced by massage, when
he speaks of the ease with which the blood seems to circulate,
of the feeling of refreshment that ensues, and of the sweet
sensations and delightful ideas that arise in the mind, and
when finally he allows himself to declare that in fancy one
overlooks the whole world, which seems to lie at one’s feet
and to grow more bright and refulgent under the observer’s
eye, and that everywhere only the laughing face of fortune is
seen; all I can say is, that unfortunately mechano-therapy has
nothing in common with these beautiful impressions and de-
lightful sensations. It usually causes a good deal of pain and
it is only in the popular acceptance of the term that the patient
“sees stars.”

After his daily manipulation the patient generally feels ex-
hausted, often experiencing for twenty minutes or half an hour,
pain which gradually disappears. The time for the repetition
of his treatment is anticipated with fear and trembling, and
only the conviction of its efficacy, or the fact that the cure has
already begun and is visibly progressing, gives him courage
and endurance to stand the torture imposed. In certain dis-
eases, as constipation, neurasthenia, and chorea, it is true,
there is no pain, or none worth mentioning, connected with
the cure; in other cases, however, the pain experienced is so
severe that patients cry out aloud, shed tears, and even Vigor,
ously resist the physician with arms and legs — a proceeding
which must not, however, be considered as sufficient ground
on which to base a charge of assault and battery !

CLASSIFICATION OF THE MECHANICAL INTEKFERENCES.

As classification is always a help to beginners, I have at-
tempted here to lay down the common characteristics of the
mechanical interferences used.

STABILE INTERFERENCES.

They may all be divided into stabUe and labile. The stabile
act by a repetition of the application to one and the same spot,
while in the labile the application is changed from one part of
the affected area to another.

Stabile interferences may be represented by a blow against
a solid body and by the propagation of the vibrations conse-
quent thereto within this body. The labile resemble undula-
tory movements.

Among stabile interferences, are included : pressing, tapping
(or beating), hacking, pinching, and concussing. As labile:
stroking, rubbing, and kneading.

No exact line, however, can be drawn between the two, for,
by a modification in their application, certain interferences
may be just as well considered stabile as labile, or one form
may pass into another; pressing, for instance, being often
transformed into kneading and squeezing.

The skill shown in applying these various modifications and
causing transitions from one to another constitutes the very
acme of dexterity in mechano-therapy.

According to circumstances, passive motions may be classed
in both categories. Active movements will receive special
consideration elsewhere.

STABILE INTERFERENCES.

Pressing.

Pressure may be performed in a variety of ways ; one, two,
or three fingers being used, according to the size of the part to
be treated, and the force which it is intended to use (see Pigs.
2 and 3).

The participation of the little finger is only apparent, for,
being two centimetres shorter than the ring finger, it cannot
touch the part to be manipulated simultaneously with the
others ; its feebleness, too, would render it at best of little use.

The index finger, to be sure, is also shorter than the middle
finger, but only by one centimetre, and it, therefore, more
readily adapts itself to the middle and ring fingers. Of the
different fingers, the thumb is of most use, owing to its short-

STABILE INTERFERENCES.

ness, strength, and to its possessing special muscles of its own
(flexor pollicis longus and brevis, extensor pollicis longus and
brevis, abductor pollicis, and opponens pollicis).

Fio. 4.

If the sensitiveness of the patient or the condition of the
parts will not allow the finger-tips to be used, the second pha-

Fig. 5.

PRESSING.

lanx of the index finger, or those of the index and middle
fingers combined, may be used (Fig. 4), or three, or even four
fingers may be associated in action.

The fact that the index and little fingers are not on the same
plane is of no import in this mode of application, for the
parts to be pressed are, as a rule, of irregular surface. Pres-
sure can be increased by using, instead of the second, the
combined third phalanges of the four fingers which form the
fist (Fig. 5). Should still greater pressure be desired, instead of
the surfaces of the combined first phalanges, the knuckles — L e.,

Fig. G.

the heads of the metatarsal bones — may be used (Fig. 6). Other
things being equal, the pressure exerted is less the more joints
there are between the shoulder of the operator and the parts
of the hand used in pressure, for a large portion of the mus-

STABILE INTERFERENCES.

cular power brought into play must necessarily be used in
the fixation of those joints. The term ‘‘other things being
equaP^ needs a word of explanation. The amount of pressure
depends a good deal on the position the physician takes toward
his patient. In a sitting and standing posture the weight of
the trunk can be used to increase pressure, and when the
patient lies extended on a couch a maximum pressure can be
obtained, for the whole weight of the trunk then helps to aug-
ment the muscular force.

Each mode of applying pressure, enumerated above, may be
modified in three ways:

First, the fingers or fist used for pressing are caused to make
slight lateral or rotatory movements [vibrations of the French).

Secondly, they are caused to move continuously from the
point of application to some other spot — upward or downward
— the stabile being thus converted into a labile interference by
pressure being simply changed to stroking, the degree of
pressure remaining the while unaltered.

Thirdly, they are caused to make very short continuous
movements, during which pressure is first increased and then
diminished. In accomplishing this the hand of the operator
leaves each time the point of application to be applied anew —
thus the procedure of “ fulling” or kneading is evolved from
that of pressing.

Tapping, Thrusting, and Hacking.

While pressing produces a constant efiect, capable of every
possible degree of increase or diminution, the three procedures
just enumerated admit only of sudden effects of momentary
duration.

The operation of tapping (or beating) is done with the tips
of the half bent fingers : the hand being moved at the wrist.
It is only capable of producing mild effects, such as are used
for neuralgias of the cranium.

Thrusting is performed with the finger-tips of the rigidly
extended hand (Fig. 7), or with the clenched fist, the arm being
moved partly from the elbow, and partly from the shoulder.

TAPPING, THRUSTING, AND HACKING. 59

The patient may be either seated or standing, and the physi-
cian^s hand impinges upon the body at a right angle.

This manipulation is useful where deeply lying parts, situated
between groups of muscles, are to be reached, as in rheuma-
tism and neuralgias in the larger muscle groups (as the but-
tocks and thighs), and also where marked effects generally
are desired. Thrusting and tapping produce in the parts so

Fig. 7.

operated on a vibration or concussion which (in nerves) propa-
gates itself from the periphery to the centre, and also molecular
changes which are transferred from those on the surface to
parts more deeply situated.

Of far more power and extensive application is the so-called
muscle hacking, a procedure which is only employed when
large groups of muscles are the seat of trouble, as in the neck,
back, buttocks, thigh and leg, and arm and forearm.

TAPPING, THEUSTING, AND HACKING.

Hacking is performed with the edge of either the extended
fingers or hand (Figs. 8 and 9), according as mild and super-
ficial or powerful and profound effects are desired. In the first
case (edge of the extended fingers) the motion originates in the

Fig. 10.

wrist-joint, the fingers being, as it were, flung against the
patient’s body, while in the second (edge of the palm) the
motion proceeds either from the elbow or from the shoulder-
joint. The latter manipulation allows of the employment of

STABILE INTEBrE€lBNOES.

the greatest amount of force, and is used on such large muscle
groups as those of the thighs, buttocks, and neck (Fig. 10).

Kxbmm’s Muscle-beater.

Muscle hacking should not be confounded with muscle
beating, which is an incomparably milder procedure.

C. Klemm, director of a calistbenic eetablishment in Riga,
first originated the very excellent idea of using for the manipu-
lation of the skin (he would include the muscles ag
Fia. 11. well) a number of thick elastic rubber tubes. These
give the patient the great advantage of being able to
manipulate himself, the services of an operator being
dispensed with. The simple and effective apparatus
known as Klemm’s muscle-beater consists of three
stout tubes, held together at one end by a rubber
handle. They are made in three different sizes, each
size differing from the others in the length and thick-
ness of the tubes.

By means of this instrument it is possible for a pa-
tient to manipulate even those parts of the body ordi-
narily not easily accessible (Figs. 12 and 13). It is
capable of effecting all the results produced by strok-
ing, gentle pressing, and hacking. Powerful effects,
such as vigorous hacking, forcible pressure, or pinching
and squeezing produce, are as much outside the
province of this elastic apparatus as they would be of the
human hand were it hollow and elastic like the muscle-beater.
At the part of the body operated upon with this instrument it
is true, the weight of the blow will extend beyond the skin as
far as the subcutaneous connective tissue, perhaps even to the
layer of fat, possibly to the muscle immediately beneath, but
to what an infinitesimally slight degree will the more deeply
situated muscles be affected ! Even using the greatest possible
amount of force, it will, after all, be the skin which receives
the brunt of the stroke.

In pinching, the fingers grasp the muscle in nearly its whole
circumference ; in pressing, the hand forces the muscle against
its bony support; and in hacking, the edge of the palm pene-

ELEMM’s UnSCLB-BEATEB.

tratea by its bony framework into the deeper regions of the
soft parts, and we should not forget, too, that these efforts can
be maintained continuously for many seconds without the skin
being subjected to any very sharp blow — all these are effects

Fig. 13.

Fig. 12.

which can be produced by the hand of the manipulator alone,
and which can never be attained by any muscle-beater.
Besides, in certain positions, as shown in Figs. 12 and 13, it is
not possible to develop any degree of force.

Ifevertheless, the muscle-beater (I would prefer the term
“skin-beater’’) will be found of use in all those cases where
superficial rather than deep parts are to be aflfected (as in the
treatment of cold hands and feet, in rheumatism of the skin
and superficial muscles, or in moderate stiffness of the joints).
Much of its use lies no doubt in the bodily exercise to which
its employment necessarily gives rise.

The pamphlet published by the inventor of the muscle-
beater excites surprise by the use, in certain parts, of scientific
language unusual in a layman. Other portions, again, give

STABILE INTEEFERENCES.

evidence of very unsound medical ideas, for, according to
Klemm, this instrument is capable of excellent service in the
greatest variety of diseases; from muscular curvature of the
spine to alopecia, and from gouty tophi to insomnia and
dizziness.

Pinching.

In places where anatomical conditions permit of the soft
parts being grasped, very powerful eftects may be produced by
pinching. There are two modifications of this manipulation.
In the first of these, the thumb on one side and the four fingers
on the other form, as it were, the jaws of a i)air of pliers acting
perpendicularly to the part operated on (Fig. 14). In the second,

Fig. 14.

the thumb and fingers are not applied with their tips, but with
the balls of the last phalanges (Fig. 15), the first procedure
being more powerful than the second. Of all the manipula-
tions that have been, or are to be described, this one, in both
its modifications, is the most fatiguing to the physician. It
requires a very powerful thumb, and in performing it the
fingers should be brought close together, for, when separated,
less force can be exerted.

SQUEEZING.

This manipulation is called malaxation or pdtrissage by the
French, and the following explanation is given : “ The physician

Pig. 15.

should treat the tissues of his patient as though he were knead-
ing hard a bit of dough, or as though he were squeezing out a
sponge saturated with water.”

Squeezing.

Squeezing is but a species of pinching, for, while in the
latter the jaws of the plier formed by the thumb and fingers
act equally from either side, in squeezing the fingers remain
passive, acting solely for fixation of the part, the thumb alone
coming into play (Fig. 16).

LABILE INTERFERENCES.

Fig. 16.

Squeezing should, at first, be applied perpendicularly to the
spot manipulated. Later, the thumb should be rubbed back
and forth, with full force over the ganglion, gland, teno-syno-
vial exudation, or whatever it is intended to squeeze.

LABILE INTERFERENCES.

Rubbing; Stroking.

That labile may be evolved from stabile manipulations we
have already seen under the head of Pressing.”

Rubbing and stroking of affected parts with the palm is
really nothing more than a gentle continuous pressing — -fric-
tions simples of the French. In the treatment of dislocations,
in which these manipulations play as important a part, it is
usually a question of the removal of extravasated blood and
lymph from the part, and at the same time of causing the
liquefaction and removal of semisolid coagula of blood and ex-
udations. Firm compression, with a forward movement of the

PASSIVE MOVEMENTS.

hands, fulfils the indications. The hands should either encircle
the limb like a band, or pressure may be made with the edge
of the palm or with the inner edge of the index finger supported
by the others. The French call this frictions fortes cl pleines
mains^ or massage proprement dit^ and it is this form of manipu-
lation which has given the name to the whole system.

PASSIVE MOVEMENTS.

We understand, by this term, all movements performed by
the physician upon the patient, the latter remaining passive.
The following results are obtained :

1. Extravasations occurring about dislocated joints are, by
pressing and rubbing the tendons and ligaments in which they
are embedded, finally liquefied, and thus more quickly absorbed.

2. In stiflFness of joints the contracted muscles and tendons
are forcibly but gradually elongated, and any existing exuda-
tions or vegetations within the joints are disintegrated and
absorbed.

3. By the forcible stretching of the muscles their nerves are
likewise stretched; molecular changes being thus set up in
both.

4. Forced extension of the muscles causes pressure on their
blood and lymphatic vessels, thus accelerating the circulation.

6. Finally, such muscles as have by rheumatic or neuralgic
pains been kept in a state of inactivity, have some of their
much needed exercise restored to them. Passive movements
thus form in certain diseases, as in neuralgia and rheumatism,
the introduction, as it were, for the far more painful active
motions which have to follow.

The pain produced by active movement is soonest overcome
if the early sensitiveness be diminished by previous passive
motions, and the patient will more readily learn to bear the
pain which he is obliged to inflict upon himself, if he has once
experienced the benefits which followed the pain caused by his
physician.

The different varieties of passive motion consist of flexion,
extension, supination, pronation, and rotation, according to the
nature of the joint involved; the force as well as the rapidity

PASSIVE MOVEMENTS.

with which these motions are performed admitting, of course,
of every possible gradation. In the beginning it will he neces-
sary to proceed very cautiously and gently, and complete
flexion, extension, or rotation should not be performed, so as
not to cause too great pain. At first the indications can be
but partially fulfilled. When the patient has become some-
what used to the pain, however, more energetic measures can
be pursued. On the other hand, if it is a question of time, and
if the patient be of strong constitution and will, vigorous pas-
sive movements may be used from the start.

Fia. 17.

In the oldest work on medical gymnastics (the Cong-FoUj
translated in the last century by the learned French mis-
sionary Pere Amiot), figures may be found (Figs. 17, 18, and

Fig. 18.

19) illustrating movements of the extremities, head, and trunk,
and intended to represent the treatment of certain diseases.

OILING OF PARTS TO BE TREATED.

Fig. 19, for instance, represents the movements used for the
cure of lumbago.^ In Hungary this means has been in use
under the name of ‘‘ Csomor,’’ since time immemorial. Its
chief practitioners there are old women.

Fig. 19.

Besides movements of the joints, we may include under
passive movement driving, riding (that is, in those cjIBes where
the patient does not take an active part), being carried in litters
or chairs [as occurs in the Swiss Alps], being swung in a
swing, etc.

SHOULD THE PARTS TO BE TREATED BE PREVIOUSLY OILED?

Heretofore, most writers have advised oiling the parts of the
body to be manipulated. I have found, however, that for many
manipulations inunction not only does not facilitate treat-
ment, but, on the contrary, renders it more difficult; and I
have, therefore, for a long time past confined its use to a few
procedures only. The nature of the different manipulations
employed is the best indication for the proper use of an
unguent. Labile manipulations, when extending over a con-
siderable surface, can perhaps best be performed with the skin
oiled, for the motion is performed in a direction from the
periphery toward the centre, and as the hairs are disposed in
an opposite course, the operator’s hand glides over them with-
out pulling or tearing, thereby saving the patient painful, or,
at least, unpleasant sensations. Stabile interferences, on the

1 N. Dally : Cln^aiologie oa Science du mouvement. Paris, 1867.

OILING OF PABTS TO BE TEEATED.

other hand, are directly impeded by inunction. The manipu-
lator’s fingers glide from the slippery surface, for a part
smeared with oil or grease can with difficulty be kneaded,
pinched, or hacked.

The supposed softening of the skin by the inunction is of no
possible use, for in nearly all cases it is a question of affecting not
the skin but the deeper parts lying beneath. If necessary,
labile manipulations may be performed with equally good
effects without previous inunction — only the sensations of the
patient are apt to be less agreeable. A story is told of the
celebrated “natural healer” Pich, who lived in Horizka, in
Bohemia, and who was originally a “ horse doctor,” lacking
all medical or even veterinary education, and who yet, by his
miraculous cures of joint troubles, became a celebrated man,
often consulted by the educated and wealthy. A lady, moving
in the best circles of Vienna, suffered from an obstinate knee-
joint trouble, which prevented her walking. After having con-
sulted in vain the talented Professor Schuh, of Vienna, and
Nelaton, then so celebrated in Paris, as well as other noted
surgeons of the day, she went, as a last resort, to Pich (which
was the means, if I mistake not, of a licentiate in medicine
being bestowed upon him later). Pich manipulated the joint,
and rubbed it plentifully with his wonderful salve. In a few
weeks the lady was cured and able to use her leg as of old.
As she was leaving, she begged some of the salve of him.
“Ah ! the salve by itself would do you no good,” answered the
sly old fellow, “ it has to be rubbed on in a particular way,
and not every one can learn how to do that !” This, which
was an actual occurrence, took place somewhere between 1860
and 1860. In the twenty-five years that have passed since then
mechano-therapy has gained for itself a fixed place in science,
and to-day, in a similar case, the professors would not have
to allow any “ wonder doctor ” to bear the palm of victory
from them.

THE BODY SHOULD BE CLOTHED.

IS TREATMENT TO BE UNDETAKEN UPON THE NAKED OR
CLOTHED BODY?

Except in sprains, where the part must necessarily be strip-
ped for treatment, mechanical manipulations should be under-
taken upon the clothed body. In many cases, indeed, I prefer
that it should be clothed, for the pain is often less, and as the
skin is not the seat of the trouble, it is more protected ; and

Fig. 20. Fig. 21.

then, again, the hand ot the operator is often enabled by the
clothing to get a better hold, ifeither men nor women, how-
ever, can be treated in their ordinary dress. Probably the

THE BODY SHOPLD BE CLOTHED,

best costume is an ordinary gymnasium suit of thin flannel, as
it readily allows all passive and active motions which form
such an indispensable part of the treatment. Linen is not
suitable, as the hand slips easily and soon becomes fatigued.

In the case of women, the question of being clothed is of
great moment, for in many instances they would refuse treat-
ment altogether had the latter to be performed on the naked
body. For them, the dress should consist of loose trowsers
coming below the knee and fastening around the calf with an
elastic band. A comfortably fitting sleeved blouse, buttoning
down the front and reaching to the middle of the thighs, serves
as a waist. A belt aids in holding up the trowsers. Thin
leather shoes should be worn. Dark colors are preferable, as
ladies do not fancy light-colored costumes, being too suggestive
of a masquerade. (Fig, 20.)

For men, the best costume consists of trowsers and under-
shirt of jersey-cloth, fitting not too tightly, with a soft woollen
belt and light leather shoes. (Fig. 21.)

CHAPTER IT.

Active movements. Calisthenics and Swedish movement-cure. Apparatus.
Physiological effects of gymnastics on the heart and circulation, on the
skin and kidneys, on corpulence, on respiration, on digestion, on the central
nervous system, and on the mind.

ACTIVE MOVEMENTS.

Active movements, like the passive ones just described, are
of great service in certain joint diseases, such as sprains, con-
tusions, pseudo-ankyloses,, chronic rheumatic arthropathies,
stiffness, synovitis, etc., also in affections of the muscles and
nerves, as neuralgia, paralysis, anaesthesia, muscular rheu-
matism, writer’s cramp, chorea, neurasthenia, etc. In all con-
stitutional troubles, also, where the object of treatment is to
simultaneously improve the quality of the blood and the tone
of the heart ami vessels, and to stimulate peristalsis and the
activity of the intestinal glands, as obtains in chlorosis, anaemia,
constipation, chronic gastritis, etc.

On the other hand, passive, as well as active movements are
entirely useless in the treatment of enlargements of glandular
organs, as in mastitis, hypertrophied lymph nodes, or uterine
subinvolution. In these cases if active and passive movements
are undertaken in conjunction with mechanical interferences,
the effects of the two must be carefully separated.

For certain cases active movement forms an indispensable
part of the mechanical treatment. In treating deep-seated
neuralgias, muscular rheumatism, constipation, or neur-
asthenia, for instance, the cure might be delayed, if not
indefinitely postponed, were not active movement combined
with the other mechanical interferences. Even in the begin-
ning active movements are to be recommended, though with
circumspection — first using the easiest and simplest forms, and
finally progressing to the more difficult.

In sprains and contusions of joints, in chronic rheumatic

74 CALISTHE>fICS AND SWEDISH MOVEMENT-CURE.

arthritis, and other joint troubles, mechanical manipulations
play the chief part. Passive motion should be resorted to late
in the course of treatment, while it is left to active movements
to crown the completed cure.

CALISTHENICS AND SWEDISH MOVEMENT-CURE.

Passive and active movements have been classed together
under the terms sanitary gymnastics or calisthenics. Several
authors have published bulky volumes on “ kinesipathy,”
kinesiatrics,” “ cinesiologie,'’ which, notwithstanding their
merits, have, through size and prolixity, deterred Jhe busy
practitioner from consulting them. In works on the Swedish
movement-cure we encounter a most absurdly difficult and
complicated nomenclature, often quite sufficient to deter the
average physician from ever attempting to engage in this line
of practice. And while I intend to give a hasty sketch of the
Swedish methods, I may as well state here that it is my firm
conviction that the general practitioner will be able to employ
this or any other form of mechano-therapy with the best re-
sults without a previous knowledge of even one of the jaw-
breaking terms applied to many of the procedures used.

Sanitary gymnastics do not necessarily differ from ordinary
gymnastics. There is, however, this essential difference
between them, that while gymnastic exercises usually aim at
influencing the body as a whole, — seeking in this way to pre-
vent organic disease and to strengthen the individual bodily,
mentally, and morally — sanitary gymnastics, on the other hand,
seek to operate on special parts of the body. By their aid
diseased portions are forced to return to their normal state,
and impaired function is restored. Naturally enough, in cer-
tain cases (as in anscmia, chlorosis, and scrofula) the end and
aim of both these forms of exercise must often be the same.

In sanitary gymnastics we seek as far as possible to isolate
separate movements by excluding the cooperation of certain
muscle groups. To accomplish this, an exact knowledge of
existing anatomical and physiological relations is absolutely
necessary. For ordinary gymnastics, where general results
only are sought to be attained, such knowledge is not requisite.

CALISTHENICS AND SWEDISH' MO VE MENT- CU BE. 75

The Swedish system seeks virtually the same ends sought
by ordinary sanitary gymnastics, only in it the isolation of the
parts to be treated is eflRected readily and simply by methods
founded on an anatomico-physiological basis, which is the in-
vention of Ling. The essence of this method consists in pre-
senting a resistance to the intended motions of the patient,
either by the physician himself or by an assistant.

76 CALISTHENICS AN© SWEDISH MOVEMENT- CURE.

Ling knew as little of this physiological fact as Priessnitz did
of the physiological action of hydrotherapy, yet both, seem-
ingly by instinct, divined the truth. By Ling’s method the
action of antagonizing muscles is eliminated by the operator,
— as will appear more plainly by an illustration.

Let us suppose a patient to be sufiering from paresis of the
flexors of the forearm. According to Ling, the flexors must

Fw. ‘JS.

therefore be strengthened by exercise. But exercise of the
whole arm is contraindicated, otherwise the antagonizers of
the paretic flexors would be strengthened as well. Ling very
correctly observed that in such a case the healthy muscles,
being more completely under the influence of the will, would
be strengthened proportionately more than the paretic ones.
A certain resistance, therefore, must be opposed to the uncon-
scious contraction of the flexors (Pig, 22) and this can be

THE USE OF APPARATUS.

effected by substituting the force of the operator for that of
the muscles. By this, the latter being put in a condition of
complete inactivity, the flexors alone are compelled to work.

Isolation of the function of a single muscle group may be
accomplished in two ways :

1. The operator opposing his power to that of the contract-
ing muscles, as in Fig. 22, the limb being extended. Ling
called this the “ concentric duplex movement.’’ Duplex, because
two individuals engage in it; concentric, because the patient’s
muscles have to overcome a resistance which prevents flexion
— L a movement toward the trunk.

2. The patient semi-flexes his forearm, thus contracting the
affected flexors, whilst the operator seeks to extend it forcibly.
(Fig. 23.)

Ling called this the “excentric duplex movement ” because
the force acted in a direction away from the body. Experi-
ence will teach the physician, or his trained assistant, to regu-
late the force necessary to be employed. In the correct
estimation of the precise amount required the superior skill of
the operator will be most clearly shown. There should never
be anything a^pproaching a struggle between patient and
operator.

THE USE OF APPARATUS.

The opinions of mechano-therapists are widely divergent
upon this question. I have already expressed myself, in
accordance with my own experience on the subject, by saying
(page 39) that a skilful operator can, with his hands, perform
everything for which another will need apparatus. Still, I
do not mean to assert that apparatus may not at times be
successfully employed ; indeed, the resistance movements,
which play the chief part in the Swedish system, can be more
accurately regulated, and good results more rapidly attained by
means of suitable apparatus than by the operator alone. Even
if we admit that the operator may have his own muscles so
under control as to be able to change at any moment the force
he employs, still, can be also measure so exactly the force of
the disabled muscles which he is called upon to resist? The
power of the operator and that of the affected muscles are

THE USE OF APPARATUS.

like the pans of a balance, of which one represents the thing
to be weighed, the other the weight itself, and to accurately
measure the former, many trials are often necessary. The
amount of resistance to be emploj^ed by the operator resolves
itself, therefore, into a simple mathematical problem, which
can be more readily and accurately solved by an inanimate
apparatus, than by a variable force constantly under the influ-
ence of the will.

Fig. 24 .

The strength used by the operator should be increased pro-
portionately as the aftected muscles become stronger. The
weight which the patient was yesterday able to lift or push
gives us a mathematical basis for increasing the weight to
be used to-day. The muscular power used by the operator
could give us no such indications. An apparatus allows, also,
the progress of the cure to be exactly measured at any time.

THE USE OF APPARATUS.

I .cannot, therefore, agree with Rossbach’s view, according to
which the human hand cannot be substituted by apparatus.
On the contrary, I consider apparatus far more useful than
the necessarily varying resistance afforded by the operator
himself.

The construction of the apparatus used is very simple.^
(Fig. 24.) For the movements of lifting or pushing, a rect-
angular cage, capable of being loaded with any desired weight.

Fig. 25.

is suspended in a suitable casing, by ropes passing over pulleys,
and furnished with wooden handles. The handles may be
either grasped by the patient’s hands, or used like stirrups

I It Ib scarcely Deceisary to add that far more handy and convenient forms of this apparatus than
figured by our author, are manufactured by dealers in athletic goods in this country.— T eaks.

THE USE OF APPABATUS.

by the feet. (Figs. 25 and 26.) It is very important to have
the apparatus securely fastened to the wall so that it cannot be
upset by any use, however violent. Each apparatus should
have several weight-cages, and the ropes should be arranged
to emerge from the casing at different heights from the floor
so as to allow of the greatest range of use.

Fig. 20 . Fig. 27 .

The cages run on tracks, and openings are left in the casing
for loading them. As the ropes may be regarded as so many
levers upon which the tnuscles act as loads, it follows that the
weight in the cage remaining the same, the force to raise it
will needs be greater the nearer the floor the handles are
placed — L e., the shorter the arms of the lever are. When the
muscles of the neck and trunk are to be exercised, the ropes

THE USE OF APPARATUS.

EFe fastened to a yoke which the patient lifts by his shoulders.
(Fig. 27.)

In all these forms of apparatus the particular muscles to be
exercised are aided by the cooperation of the whole body, but
for isolation of special muscle groups the following arrange-
ments shown in Figs. 28 and 29 have been devised.

When a person lies prone upon his belly it is clear that in
moving the rope handles outward no other muscles except

Fjg. 28 .

those of the shoulders and arms are called into action. On the
same principle, the leg and thigh muscles only are used when
the patient attempts, in a sitting posture, to push the weighted
foot-boards with his feet — as shown in Fig. 29.

It is always best to increase the work of the affected muscles
quite gradually, so as to prevent their becoming too soon

THE USE OF APPABATUS.

fatigued. A few minutes of rest, also, should be taken between
each exercise.

The general principles governing the application of muscular
exercise, as laid down above, were first systematized by Ling,
and their correctness has been confirmed by every one who
has since busied himself with the subject. They are so
clear and simple that it is to be regretted that Ling adopted

Fig.

for their description so complicated a nomenclature that it
has tended rather to confuse the subject than to elucidate it,
and although the specialist may not be deterred in conse-
quence, yet it has certainly put great obstacles in the way of
the methods being generally adopted.

Ling recognized five chief primary positions for all move-
ments. These were standing^ sitting^ kneeling^ and hanging.

THE USE OF APPAKATUS.

•88

These primary positions were subsequently modified and
recombined, so that so-called binary,” “ternary,” and “ quar-
ternary ” positions were formed. Thus the position of simple
standing underwent a fourfold modification, as follows :

First. By the position of the feet, into standing close, standing
apart, toe-standing, gait-standing.

Second. By position of the arms, into

[The translator is here obliged to pause, for as the Anglo-
Saxon mind is happily unable to conceive the absurdities of
Ling’s nomenclature, the English language is naturally not
adapted for the expression of its terms — that is, in single
words. In German, as is w^ell known, it is justifiable to
coin almost as many new words as the necessity of the user
calls for; hence there appears — to a German, at least — no difli-
culty in rendering Ling’s terras. Provided these terms were at
all intelligible — which they are not — it would require several
paragraphs at least to render one of them into English. That
this statement may not seem exaggerated, I will instance as an
example the German term for what is called the quarternary
combination of the standing position. It contains forty-five
letters and nine separate words, though it is written in German
as a single word. This literary curiosity I give in one line,
separating the words by hyphens, however, for the sake of the
English reader, and on the line below the translation of each
word will be found.

Links-ruh-rechts-streck-gang-links-seits-stiitz-stehen.

Left-rest-right-extended-gait-left-side-support-standing.

It would seem as though only a professional “ man-snake ”
could assume the positions which such a verbal contortion
implies. At any rate, the reader is at liberty to try it himself,
and should he escape without accident, an account of his
eflforts will certainly be appreciated by the public in general,
and by the translator in particular.]

The opinion of a scientist like Du Bois-Reymond, on the
Swedish system, is worth recording. He says ; “ There can
really be no serious questioning regarding the scientific found-
ation of Ling’s system. A mere glance at his writings is
enough to show that they are a product of that miserable

THE USE OP APPARATUS.

^ natural philosophy ’ which for a quarter of a century made a
laughing-stock of German science. His arbitrary constructions,
his empty-sounding symbolism, his meaningless scheraatiza-
tions, and pedantic terminology no doubt impose on such semi-
educated minds which, unable to detect the nonsense, accept a
few scraps of anatomy and physiology as evidences of profound
learning. For him who has any conception at all of scientific
aims it will require no little resolution to wade through writ-
ings in which one might reasonably expect to find at least a
few valuable facts deposited by this well-meaning though misled
individual, whose whole life was devoted to but this one
pursuit. But here, too, we are doomed to disappointment.
What there is in the book is laid down in a trivial, dogmatic
way, and might, the principles being given, have been deduced
by any one. I^othing whatever in Ling’s writings indicates a
truly physiologically conceived explanation of the underlying
facts.

The comprehensive work of Eothstein, a pupil of Ling, may
be compared to a great flowing, full-bottomed wig, of a thous-
and ambrosial curls, placed upon a puppet’s empty head. The
puppet’s head is the limited, hollow, lifeless system of Ling.
This forms the nucleus of the book, while the wig upon it is
formed of a vast material most diligently collected from every
quarter. It often conceals the simplicity of the system, it is
true, but at the same time it makes it seem more worthy and
attractive. Elaboration is so piled upon elaboration that the
real subject under discussion is often, for a long time, lost to
view.”

‘‘ The philosophic, ethic, aesthetic, political, pedagogic, philo^
logical, theological, and historical lucubrations need not concern
us. Of those anatomico-physiological excursions to which the
author treats the reader, I am sorry to say, that they are utterly
valueless. His anatomy is made up of extracts taken from the
little handbook of Wilson and Hollstein, while in physiology he
jumbles together antiquated views with modern facts in a way
to display that total lack of scientific judgment not seldom seen
in laymen, who think that to achieve a certain end they can,
self-taught, master the most complex subjects. A state of
confusion has been thus introduced which surpasses all belief,

THE USE OF APPAKATUS.

and which renders any serious criticism of the work as difficult
as it would be easy, by the quotation of a few of his own sen-
tences, to hold the author up to ridicule.”

Perhaps Du Bois-Reymond is a little extreme in his views,
but it is not my province to investigate here how far the
stringent sentence of the great physiologist is justified. Cer-
tainly the pompous claims made for mechano-therapy — or, as
it is often termed, Swedish gymnastics — to be a universal
remedy deserve the severest castigation. Some physicians
have asserted to have cured cardiac hypertrophy and atrophy,
valvular insufficiency and stenosis, etc., with it, and Ifeu-
mann even went so far as to say that the effects of gymnastics
extended to the ciliated epithelium !

The part chance plays in the cure of chronic illness should
never be forgotten. What impotent conclusions are not
constantly being drawn from ascribing a cure to some op-
portunely given remedy? Still, in rejecting part, all need
not be thrown away ; and Ling deserves undying praise, if for
nothing else than that he turned the attention of inquiring and
educated physicians once more to a long-forgotten but potent
therapeutic means. It is a mistake, however, to try to force
physiological explanations for all the means used or the cures
that follow. For the present we must rest content in simply
searching for the proper explanation and in unravelling the
yet remaining obscurities of the subject, rejoicing in the
meanwhile in the brilliant successes obtained. Does our
ignorance of the physiological action of quinine in causing the
splenic enlargement of intermittent fever to disappear, deter
us from using this well-tried febrifuge ?

Thirty years ago, Romberg, though himself using and
recommending Swedish gymnastics, nevertheless had already
sharply criticised the extreme direction taken in it by Dr.
Neumann in Berlin. Ling’s system but shared the fate of all
new doctrines, which are either persistently denounced, or
by enthusiasts lauded to the skies as panaceas for all ills.

Eulenberg, in whose work^ the golden mean between these
two extremes is happily observed, makes the remark that

1 M. Eulenborg : Die Schwediache Heilgymnastik. Berlin, 1863.

86 PHYSIOLOGICAL EFFECTS OF GYMNASTICS.

Ling’s method is the only truly rational therapeutic means for
the cure of chronic disturbances of motility, such as result
from spinal curvature, for pseudo-ankylosis, the phthisical ten-
dency, pigeon-breast, peripheral paralysis, etc. Even in cases
of paralysis from lesions of the cord, it may still effect a
cure, ’where all other measures, undertaken after the original
disease has run its course, will be found useless. Ling’s
gymnastics have an even greater and more certain effect upon
innervation and nutrition than the common form of gym-
nastic exercises. Spinal [lateral] curvatures resulting from
faulty carriage (in consequence of a preponderance of muscular
force of one side of the body) are nowadays never treated
by any good orthoppedist by any other means than the
Swedish system. Still, equally good results are obtained by
purely active (German) therapeutic gymnastics, when intelli-
gently applied, as when active and passive movements are
combined. One great advantage which the use of the German
form has, arises from the simple and easily understood terms
employed. How indicative of the movements to be performed
are, for instance, such terms as finger-flexion, arm-rotation,
leg-lifting, knee-extension, body-circling, shoulder-hitting,
elbows back, hewing, mowing, etc.

In 1835, Stromeyer declared that of all means employed in
orthopaedy against spinal curvature, gymnastics was the most
effective and rapid. He did not think a differentiation of the
means employed, according to the varying pathological
conditions causing curvature, possible at that period ; but he
recognized, nevertheless, the merit of the Hanoverian royal
physician, Leutin, who first recommended suspension by the
hands for this affection. The treatment of scolioses by the
Ling system, which has scored some of its greatest successes
in this very department, requires, however, quite a special
study, and can hardly be carried out without both apparatus
and trained assistants.

PHYSIOLOGICAL EFFECTS OF GYMNASTICS.

The powerful influence exerted by bodily exercise upon the
health, and its secondary effects upon the activity of the brain

EFFECTS UPON THE CIBCULATION AND HEART. 87

and nervous system generally, was well known in ancient
times, as the Roman proverb, Mens sana in corpore sano^ attests.

I. Effects upon the Circulation and Heart.

In the Cong-Fou of the Chinese, previously alluded to in
the Introduction, it is stated that the circulation in the human
body meets with two great obstacles, namely, gravity and
friction, and that all manipulations and bodily exercises tend-
ing to diminish these, promote circulation. The influence,
also, of the respiratory movements upon the circulation and
heart’s action was also familiar, as we gather from the Cong-
Fou, to the Chinese, and from them probably the knowledge
was transferred to the Greeks and Romans.

Dally^ claims that Ling himself obtained the idea of his
respiration exercises from the Cong-Foii, or rather from Pere
Amniot.

In the works of Orisabius (360 after Christ) w^e find a defence
of the theory that active respiration helps to eliminate the
eflfete materials (especially COg) of the body, and to stimulate
the digestive and other functions. All physicians recognize
that systematic exercise is one of the best means of preserving
and restoring the proper balance in the distribution of blood
in the body. By exercise, local hypersemias, whose persistence
may lead to the greatest variety of derangements, can be made
to disappear. The cerebral hypereemias of brain-workers, the
abdominal hypersemia developed in sedentary pursuits, and
the hypersemia of the sexual organs occurring in individuals
given to venereal excesses, are amenable to no treatment so
quickly and thoroughly as to active muscular exercise.

In a recent work,^ Sommerbrot has shown that in all exercises
increasing intrabronchial pressure, as singing, laughing, row-
ing, swimming, running, etc., two sets of effects are produced
on the circulatory apparatus. These are: 1. Diminished
tension of arterial walls. 2. Increased heart’s action. As
soon as exercise ceases, arterial tension rises again, while the

1 N. Dally : Oin6siologio. Paris, 1857-

2 Sommerbrot : Ueber eine bishor Dicht gekaDUto wiclitige Einrichtung des menBchlichen
Organismus. Tubingen, 1884.

88 PHYSIOLOGICAL EFFECTS OF GYMNASTICS.

heart’s action becomes slow. Sommerbrot looks upon these
phenomena as resulting reflexly from irritation of the sensory
pulmonary nerves. Intrabronchial pressure becomes, there-
fore, a regulator of the rapidity of the blood current. All
muscular activity, however, increases intrabronchial pressure
by decreasing the amount of oxygen and increasing the
quantity of carbonic acid in the blood, thereby stimulating the
respiratory centre and causing respiration to be more rapid
and deeper. The effects of muscular activity are, therefore,
increased use of blood, and consequent consumption of oxygen
(for the body when active consumes four to five times as much
oxygen as during quiescence), increased renal activity, and,
lastly, regulation of temperature.

We have seen (Chapter 11.) that the vessels of a muscle
in a state of activity are dilated, and that there is a resulting
increased supply of blood. Hence it follows that these
dilated vessels serve as so many reservoirs into which the
congested internal organs can pour their surplus blood. The
efiects of bodily exercise upon relieving the portal circulation,
arise first from the augmented rapidity of the blood current
resulting from increased peristalsis, and, secondly, from the
operation of a direct mechanical force, namely, the contraction
of the abdominal muscles; which, by diminishing the cavity
of the abdomen forces the blood toward the heart.

Increased oxygen consumption by the active muscle means
increased elimination of tissue waste, and a proportionate
increase in nourishment and strength. From the nervous sup-
ply being also better nourished, there arises that pleasant sen-
sation of energy and bodily vigor which always follows hearty
exercise.

Muscular exercise is an excellent prophylactic against that
very common disease of old age, arterial sclerosis, and its
attendant cardiac hypertrophy.

In corpulent persons, the deposits of fat in the abdominal
cavity cause, at first, compression of the larger intestinal veins,
and, finally, of the smaller arteries as well. Large accumula-
tions of gas are also apt to occur in these individuals from
feeble peristalsis and the retention of feces in the alimentary
canal. The vessels of the intestinal walls consequently become

EFFECTS ON THE DEPOSITION OF FAT.

compressed between the gas from within and the fat from
without, and the blood, thus driven from the abdomen, sur-
charges the circulation of the rest of the body. One inevitable
result of this overfilling is venous dilatation, just as in preg-
nant women pressure of the gravid uterus against the great
venous trunks in the pelvis causes varicosities of the veins of
the lower extremities. As the overfilling increases, the circu-
latory disturbance is propagated from the veins to the capil-
laries, and, finally, to the great arterial trunks themselves.
The last link in the chain — one that develops gradually during
the course of years — is increased aortic blood-pressure and all
the consequences which follow in its train (cardiac hypertrophy
and arterial sclerosis).

No method for preventing or relieving portal congestion
can surpass in efficiency the employment of systematic exercise
of the abdominal muscles.

II. Effect on the Skin and Kidneys.

It has been determined by Voit and Pettenkofer, that both
the velocity of the circulation and the arterial pressure are
increased by muscular exercise, and that there results, in con-
sequence, a correspondingly increased elimination of water by
both skin and kidneys. The perspiration following exercise
is a patent instance of this. During a state of muscular inac-
tivity, therefore, skin and kidneys both act less energetically,
and a certain retention of water^ must occur, giving rise to a
variety of disturbances.

III. Effects on the Deposition of Eat.

Prolonged bodily inactivity causes an accumulation of fat
to occur in the body as the direct result of lowered oxidative
processes. The fatter the body is, however, the less the
respiratory vigor, the quantity of blood becoming corre-
spondingly diminished.^ Active exercise is well recognized,

1 This is an error. Cohnhelm and Lichtheim have shown that the total mass of blood in the body
is always approximately the same, and that it cannot be either permanently increased or dimin-
ished. An actual hydrsemic plethora, therefore, never occurs, though a relcUtve increase in the
amount of water in the blood frequently results in annemia from any cause. — Trans.

® This statement regarding a diminution in quantity of the blood is equally erroneous. See pre-
ceding note. — Trans.

90 PHYSIOLOGICAL EFFECTS OF GYMNASTICS.

not only as a prophylactic, but also as a curative means
against excessive deposits of fat, and in fattening animals this
physiological fact has been observed since time immemorial,
long before its scientific reason was recognized. Thus, geese
intended for fattening are kept in narrow coops where move-
ment is made impossible. A working ox, on the other hand,
never gets fat. Cab horses, which are on the go night and
day, have good, strong muscles, though their bones often seem
to be coming through the skin. Give them but a few weeks’
rest and their bodies tend to fill out, ev^en though they may
be receiving, at the time, less fodder than before.

As we have already seen in discussing the physiological
effects of mechanical interferences, increased muscular activity
goes hand in hand with increased heat production, and this in
turn with changes in the molecular condition of the primitive
elements of the organs (muscle and nerve-fibres) involved, the
result being greatly augmented metabolism. Eossbach^ calls
attention to the fact that after the severest muscular work the
amount of albumin — that which forms the most abundant and
important element of the body — is not affected, and that the
elimination of nitrogen is not increased ; consequently, that
the real source of maintenance of power is not diminished.

IV. Influence on Respiration.

Bodily exercise increases both the action of the heart and
the activity of the oxidative processes. For the latter an
increased supply of air is a necessity which forces the in-
dividual to more energetic breathing. The deeper and more
powerful respirations which ensue expand the lungs, thus
strengthening by exercise the elastic tissue of the alveoli.
(According to Du Bois-Eeymond, every tissue of the body,
even horny tissue, is capable of being exercised.)

V. Influence on Digestion.

All exercises which call the abdominal muscles into play,
by compressing the abdominal contents, stimulate both the
portal circulation and peristalsis. The chyle, in consequence.

1 Rossbach: Lehrbuch der pbyBikaliBchen Heilmethoden, ll. Heft. Berlin, 1882.

INFLUENCE ON NERVOUS SYSTEM AND MIND. 91

is more rapidly absorbed and carried away by the abdominal
lymphatics to the thoracic duct. Thus the digestive powers
are increased and at the same time the desire for food grows
more frequent and marked, and the augmentation of the food
supply which follows, and the more thorough elaboration and
assimilation which occur, all combine to produce an improve-
ment in the general quality of the blood. Hence the surpris-
ing effects of gymnastics in all those chronic maladies which
arise from impaired digestion, such as scrofula, chlorosis, and
anaemia.

VI. Influence on the Central Nervous System and on

THE Mind.

Nearly all chronic diseases in which impoverishment of the
blood exists, or which are caused by circulatory disturbances,
exert generally a markedly bad effect upon the central nervous
system. Individuals so afflicted become hypochondriacal, lose
interest in things about them, and are frequently subject to
irritability of temper. These mental symptoms are, in great
part, but exponents of an ill-nourished brain.

Muscular exertion, by increasing blood pressure, and causing
abdominal congestion to disappear, puts new life and energy
into the organism, while the simultaneous exercise of the neces-
sary will power for the execution of these exercises awakens
a fresh interest in life. In individuals who, by reason of
mental over-exertion, are the victims of exhausting sleepless-
ness, depression, and indifference to life generally, gymnastics
are of incalculable value for procuring a normal, healthy, and
refreshing sleep. Indeed, it may be regarded as often the only
saving means in cases where this condition has produced a
state almost akin to insanity, and where all other remedies
have failed.

Henneberg has proved that during sleep a greater accumu-
lation of oxygen occurs in blood and muscle in a muscular
individual than in a weakly or corpulent one, and that the
former in consequence feels fresher and stronger on waking
than the latter. Upon those mental disturbances, which arise

92 PHYSIOLOGICAL EFFECTS OF GYMNASTICS.

not from chronic maladies, but from physical causes, bodily
exercise has a similarly beneficial eflFect.

Du Bois-Reymond has presented us with some very interest-
ing and entirely new ideas upon muscular exercise. He
shows' that muscular exercises are really not so much exercises
of the muscular as they are of the central nervous system,
especially of the brain and cord. The train of thought of this
great thinker is such a fiiscinating one that I cannot forbear
the temptation of quoting it here at length. He says : “ By
exercise we usually understand the frequent repetition,
seconded by the aid of the mind, of some more or less com-
plex action of the body, for the purpose of attaining per-
fection in that exercise, or, it may be, the exercise of the
mind alone. In physiological text-books we generally seek in
vain for information upon exercise, and if an}^ is vouchsafed
at all, it is with regard to bodily exercises; and these are
considered solely as exercises of the muscular system. [N’ow,
it is of course true that for such exercises as gymnastics,
fencing, swimming, riding, dancing, skating, etc., a certain
degree of muscular force is requisite, but we may very well
imagine an individual with muscles like the Farnese Her-
cules, and yet unable either to stand or walk, let alone to
execute complex movements. This we see when we deprive
him of the power of regulating and coordinating his move-
ments, by giving him chloroform or making him drunk. It is
plain, therefore, that every motion of our body depends, not
so much upon the force of the contractions of the muscles,
as upon the harmony of their action. To execute any com-
plex act, as a leap, for instance, each muscle must begin to
contract at exactly the right moment, and the force exerted
by each must, according to definite laws, increase, continue,
and diminish again, in order to effect the suitable position of
the limbs, and to propel at the proper speed the centre of
gravity of the body in the desired direction.

‘‘ We have as yet but little knowledge of the mechanism by
which we measure oflF to muscular energy the period of its
continuance, our researches so far having only enlightened us

^ Emil Du Bois-Reymond : On Exercise. An Address delivered at the celebration of the founding
of the military medical institutions, August 2, 1881. Berlin, 1881.

INFLUENCE ON NEEVOUS SYSTEM AND MIND. 93

regarding contractions resulting from stimuli of infinitesimally
short duration, and on tetanus. We have reason to believe —
in spite of its not occurring in these two extreme cases — that,
as a rule, the muscle promptly obeys the nerve, and that its
degree of contractility for each moment is determined by the
degree of irritability of the nerve which obtained at the moment
just preceding. Since the nerves are merely organs for the
conduction of impulses originating in the motor cells, it follows
that the actual mechanism of every complex motion must have
its seat in the central nervous system ; and consequently that
practising exercises is nothing more than the schooling of the
central nervous system. The latter has the wonderful faculty
of causing series of motions, which it has previously frequently
imitated, to recur in all their varied modulations as soon as
the proper volitional impulse (which, however complicated, is
effected only as a unit) goes forth for their accomplishment.
All species of bodily exercises, therefore, are not simply mus-
cular gymnastics, but nerve gymnastics too.^’

This twofold nature of bodily exercise had already been
recognized by Johannes Muller, but he did not emphasize the
fact enough. He made an observation, however, which strik-
ingly confirms the truth of Du Bois-Reymond’s statements,
namely, that perfection in bodily exercise consists often as
much in the suppression of useless movements as in the ac-
quirement of those desired. The gymnastic treatment of
chorea depends, indeed, chiefiy on the recognition and utiliza-
tion of this physiological fact.

It is only necessary to watch, says Du Bois-Reymond, a boy
for the first time climbing a ladder by means of his hands;
how, although it is only a hindrance, he throws his legs about
with each movement of his arms. In a few weeks, however,
the hip-, knee-, and ankle-joints will be kept well extended, the
legs close together.

Of the mechanism of inhibition of correlated movements we
know nothing; but it is evident that where by practice the
suppression of certain muscular actions has been attained, it
would not be justifiable to regard the outcome of this practice
as having resulted in the simple strengthening of these partic-
ular muscles, though we are inclined, at first sight, to look

94 PHYSIOLOGICAL EFFECTS OF GYMNASTICS.

upon every exercise as having in view a positive increase of
muscular power.

Something besides mere muscular control must come into
play during the execution of complex movements. The eye,
pressure, and the muscular senses, and, indeed, the intellect
itself must all be constantly on the alert to perceive instantly
each changing position of the body, in order that the key,
conveying the impulses to each muscle, may be struck at
exactly the proper moment. It is not the motor nervous
apparatus alone, therefore, that is capable of cultivation by
muscular exercise, but the sensory and the mental functions
as well, — the importance of the muscles, merely as such,
becoming relegated to a less lofty place in the system of
gymnastics. What has been stated here of the coarser kinds
of movements, is equally true of every species of dexterity, A
Liszt or a Rubenstein is hardly conceivable without an arm,
whose muscles are like iron, and in the use of Joachim’s
violin bow during the performance of a symphony many kilo-
grammetres of force must be expended ; nevertheless the skill
of these artists lies not so much in their muscular as in their
central nervous system. The dexterity of a turner, of a
machinist, or of a watchmaker, skill in writing, drawing, or
needlework, and in those humble jet none the less artificially
acquired operations of our daily life, as dressing, using a knife
and fork, etc., vrhat are they after all but connections between
the various ganglion cells, painfully established at first, but
which, after having been traversed for a certain number of
times, cause the operation to be performed with the greatest
ease and harmony, and finally in an entirely automatic
manner.

The chemical changes which follow muscular work afford
a ready index to the great value of gymnastics. The details
of these processes may be found, by those who wish to
consult the particulars, in the recent work of Fick^ on the
subject. We content ourselves in giving only his conclusions.

He is of opinion that muscular contraction, which of all vital
phenomena appears at first sight the most inexplicable and

1 Tick ; Mechaniache Arbiet und Wiirmeentwicklung bei der Muskelthfttigkeit. Leipzig, 1882.

INFLUENCE ON NERVOUS SYSTEM AND MIND. 95

enigmatical, is in reality capable of a mechanical interpreta-
tion. The fundamental phenomenon of organic life consists
of a change in form of the protoplasmic elements — the result
of stimulation. This change of form (movement) is micro-
scopically demonstrable. In the muscle fibre, however, where
the protoplasmic molecules are arranged in innumerable par-
allel rows, this change of form eludes even the microscope.

Fiek calls muscle substance “ crystallized protoplasm,” and
thinks it not improbable that some day it will be possible
to artificially imitate muscular contraction.

From such simple observations as may easily be made upon
ourselves it is evident that certain chemical changes occur in
muscle as the result of work. Every one knows that after a
group of muscles has been forcibly exercised for some time the
response to the will is no longer so prompt as before. This
phenomenon, known as fatigue, proves conclusively that some
intrinsic change must have occurred in the muscle itself as a
result of the work performed, for had the muscle remained
atomically unaltered there is no reason why it should no longer
react to each fresh impulse of will, or nervous stimulus, sent
to it. So long, however, as the muscle preserves its connection
with the body intact, this condition of fatigue will disappear
again, by metabolic changes being brought about by the cir-
culating blood. There are, indeed, muscles in which the com-
pensation for destructive changes resulting from work exactly
coincides with their functional activity, so that it is possible
for them to continue in action for a lifetime without expe-
riencing either interruption or fatigue, as in the case of the
heart. It is evident, therefore, that the signs of fatigue will
soonest show themselves in muscles which are deprived of
their blood supply from being isolated from the rest of the
body.

There is another well-known sign which points to the nature
of these chemical changes, namely, the increased demand for
air, indicated by shortness of breath. On going up a flight
of stairs, we notice that the number and depth of the respi-
ratory acts are involuntarily increased, and we know that
by increased respiration the introduction of oxygen and the
elimination of carbon dioxide are correspondingly augmented.

96 PHYSIOLOGICAL EFFECTS OF GYMNASTICS.

But we know, also, from genera] experience that the degree
of intensity of the respiratory act is automatically adapted
to the wants of the organism ; for were not all the organic
functions thus arranged, death would soon ensue. We are
consequently justified in concluding that this increased res-
piration at times of great muscular energy is an evidence
that more oxygen is consumed in the body during periods
of activity than during repose, or, in other words, that con-
comitant with muscular energy increased combustion of the
carbon compounds of the body takes place. Wherever com-
bustion occurs — that is, wherever chemical action is going on
— a part of the effect always consists in the creation of irregular
molecular vibrations, which manifest themselves as heat.

It is a constant experience that increased production of
heat accompanies muscular exertion. The temperature of the
whole body rises during muscular activitj^ and especially is
this true of the skin, on account of the increased blood supply
which occurs in it. Unless the surrounding atmosphere is too
cold, the skin soon becomes bathed in perspiration, which by
its evaporation keeps the body temperature always at the nor-
mal point. Thermo-electric experimentation, also, has afforded
direct proof that muscular tetany is accompanied by the evolu-
tion of heat. The experiments of Helmholtz and Heidenhain
on this subject will be found in the work of Fick, just cited.

The comparison made by some physiologists between a
muscle and a steam engine is quite apt. As in the fire-place
of the engine, so too in the muscle, combustion of carbon and
hydrogen compounds takes place. In the steam engine,
chemical energy is utilized for the exploitation of the latent
heat contained in the combustible gases of the coal ; this heat
being transferred to the water in the boiler, where part of
it, by means of a suitable mechanism, is converted into other
forms of energy, while another portion either escapes into the
air or is conducted into the cold water of the condensor.

It would not perhaps be unreasonable to assume that anal-
ogous processes occur in the muscles. Each fibre may be
supposed to contain a substance ready to undergo combustion
under the influence of a nerve impulse; that the heat so
produced is in part used for the production of work by a

INPLUBNOK ON NBEVOUS STSTEM AND MIND. 97

microscopically small machine, and in part carried away by
the circulation as such. The muscle, consequently, is to be
regarded as a thermo-dynamic machine. Experiments made
for the solution of this supposition show, however, that the
normal muscular contraction is not a thermo-dynamic pro-
cess, in which the heat produced by combustion is primary,
and the conversion into mechanical energy secondary. On the
contrary, the needful chemical affinities are, from the very
start, arranged for, and bear direct relation to, the mechanical
end in view. That this process should take place, however,
without any irregular molecular vibrations is, a priori^ very
unlikely; and as an actual fact, therefore, we do see that
besides the mechanical effects of muscular contraction there is
also production of heat.

CHAPTEE Y.

ON THE DISEASES SUITED TO THE APPLICATION OP
MECHANO-THERAPY.

In order to keep the object with which this book is written
strictly in view, we will consider here only such maladies
whose successful treatment by mechanical means is beyond all
doubt, and is generally recognized by the whole medical pro-
fession.

It has of late been the fashion to call mechano-therapy — vulgOj
“ massage ” — into requisition for the treatment of every con-
ceivable pathological condition; and then, from the observation
of a few or even single cases, to ascribe the cure obtained to
the treatment used. Nothing can be more hazardous to the
success of a new therapeutic measure than to form an opinion
regarding either its efficacy or its uselessness from insufficient
observation ; this is true both for such diseases as would either
recover of themselves, no matter what the treatment, as well
as for such as resist all forms of cure.

A severely critical interpretation of Gerst’s^ results, for in-
stance, is necessary when we read of his curing by massage
acute catarrhs of the nose, pharynx, Eustachian tube, middle
ear, larynx, and tonsils; or when he states having observed
considerable improvement within a month, in a case of chronic
ulcerative laryngitis complicating pulmonary phthisis, which
he treated by stroking either side of the neck and larynx, —
not omitting, however, at the same time, to use inhalations of
a carbolized spray !

An acute tonsillitis disappearing after three days' treatment
by massage, even if seven such cases have been observed, can
form no basis for the conclusion that the cure was due to the
treatment, for such inflammations will generally disappear
without any treatment whatever.

Gerst: Ueber den therapeutiechen Werth der Mjisaage. Wllrzburg, 1879.

TBBATMBKT OF DISEASES BY MEOH ANO-THEBAPT. 90

If Gerst could cite fifty cases of tubercular laryngeal ulcer
materially improved by stroking the neck, some conclusions
might perhaps be legitimately drawn. Influenced by Gersfs
reports, I have, during the past two years, patiently and per-
sistently used stroking in numerous cases of phthisical ulcera-
tions for many weeks, without being able to see the slightest
improvement. I have, very rarely, it is true, observed these
ulcers to heal spontaneously.

For a new method to be recommended and adopted it must,
in the first place, either be a more rapid means of cure than
others, or it must prove itself effective where all other meas-
ures have failed.

It is necessary that in all our investigations we should be
strictly guided by these two considerations.

Mechano-therapy will, in accordance with its physiological
eftects, be successful where it is desired to produce the follow-
ing results :

1. To cause an increased flow of blood to muscles and soft
parts, increasing thereby the circulation and removing accu-
mulations of tissue waste, whose retention causes various dis-
turbances of function. To strengthen muscle fibres, and by
setting up molecular vibrations to induce changes, not only in
the muscle and nerve fibres, but perhaps even in the nerve
centres themselves.

2. To cause the resorption of exudations, transudations, and
infiltrations in such organs as are accessible. To eflfect the
separation of adhesions in tendon sheaths and in joints, without
recourse to the knife. To remove, b}^ grinding away, intra-
arthritic vegetations. (Direct effect.)

3. To increase, by passive and active exercise of all the
muscles, the oxidizing powers of the blood, in this way cor-
recting disturbances in its composition, and stimulating all the
vegetative processes.

4. To relieve the congestion of such internal organs as the
brain, lungs, intestines, uterus, kidneys, etc., by increasing
the flow of blood to the muscles.

5. To stimulate directly the sympathetic nervous system,
thus increasing secretion, and reflexly the activity of unstriped
muscle fibre, and so relieving various functional derangements.

100 TEEATMBNT OF DISEASES BY MECHANO- THERAPY.

6. By systematic exercise (health gymnastics), to educate
morbidly affected muscles, to convert abnormal into normal
actions, and to suppress useless movements.

I have, in accordance with these physiological effects, sought
to arrange the diseases amenable to mechano-therapy into six
groups. I am, however, well aware that these divisions can-
not be sharply separated from one another, and that some
diseases placed in one group will combine with their own the
physiological effects ranged under other groups. Nor am I
unconscious of the incompleteness of this arrangement, but,
as it is founded upon a physiological basis easily surveyed, I
think it will prove more useful to the beginner than the more
usual arrangement (especially common in French works) ac-
cording to the topography of the body.

GROUP I. MECHANO-THERAPY OF NEURALGIAS AND
MUSCULAR RHEUMATISM.

The treatment of these two conditions may be disposed of
under one heading, since it is the same for both. The chief
symptoms of each are great pain and disturbed function. In
both the actual nature of the diseases is not known with any
certainty, nor does their pathological anatomy seemingly afford
any clew; medical writers, consequently, are forced to rely
upon hypotheses and surmises. Regarding the changes in the
sensory nerves in neuralgia and myalgia we know nothing.
So great is the obscurity involving the nature of neuralgia
that Erb ‘ regards as premature all definitely formulated ex-
planations of the subject, and Senator,^ in the introduction to
his work on the locomotor apparatus, says : ‘ Muscular rheu-

matism ’ is a heading under which are, at present, ranged all
troubles, both in the muscles themselves and their neighbor-
hood, and which cannot be elsewhere placed. Of it, it may
be said, to paraphrase the old rule in the grammar, pains
which cannot be defined may be regarded as rheumatism.’’

J. Mortimer Granville^ regards abnormal vibrations in the

1 Erb : Handbuch der Erankheiten de» Nervensystems, 11. Leipzig, 187C. [ZieinsMon's Cyclopeedia,
Am. Ed.]

3 Senator : Handbuch der Krankheiten dee Bewegungs-Apparatee. Leipzig, 1879. [Ziemssen’s
Cyclopaedia, Am. Ed.]

> Granville : Percussion as a cure for nervous derangements, Brit. Med. Journal, 1882, No. II.

NEURALGIAS AND MUSCULAR RHEUMATISM. 101

nerve fibres as the cause of neuralgia. Mechanical vibration
of the nerves is considered by him to remove pain by convert-
ing the abnormal into normal vibrations. To this end he
employs an instrument, a percussor, with which a certain
number of blows a minute may be given.

It is not always easy to make a sharp distinction between
the diseases, for the two not infrequently coexist. Indeed,
since no pathological changes have as yet been discovered in
the muscles in muscular rheumatism, one hypothesis declares
this disease to be nothing else than a morbid irritation of the
sensory nerve-endings of the affected parts.

The differential diagnosis is generally made on the character
and distribution of the pain.

In neuralgia the pain is felt along the course of the supply-
ing nerve and it branches, while in myalgia it is more diffuse,
being distributed over a whole muscle or group of muscles.
Neuralgia also is marked by typical exacerbations, while the
pain of mj^algia is usually continuous.

It would seem, from the fact that both diseases are caused
by sudden changes of temperature, or by exposure to drafts,
and that mechanical treatment is more quick and sure than
any other, that the origin of both is to be sought in molecular
changes occurring in the muscle and nerve elements.

In certain individuals a neuralgia or myalgia will make its
appearance whenever a certain part is exposed to drafts or
cold, and will disappear again as soon as the part is warmed,
rubbed, or kneaded, or passively or actively exercised — for
heat, according to present views, is but a form of molecular
motion.

It is such a well-known fact that neuralgia and muscular
rheumatism disappear after other than mechanical treatment,
and often, indeed, after no treatment whatever, that in claim-
ing brilliant results for mechano-therapy in this field, we are
only justified in doing so for long-standing cases that have
resisted all other means.

It is of prime importance before attempting the mechanical
treatment of either neuralgia or myalgia to eliminate even the
possibility of the existence of certain inflammatory processes
as neuritis, periostitis, arthritis, spinal caries, coxitis, etc., for

102 TREATMENT OP DISEASES BY MEOHANO- THERAPY.

their presence contraindicates this form of treatment. For
the ultimately favorable issue of mechanical treatment, the
nature of the neuralgia, whether of central or peripheral
origin, or whether the result of a painful affection of a nerve
trunk, or plexus, or of some muscle or tendon, is, of course,
not immaterial.

Still, even in cases where the nature of the affection is ob-
scure (and many diseases of central origin, as tabes, for instance,
have neuralgias among their early prodromata) mechano-
therapy can, at least, do no harm, Erb says: “Every expe-
rienced physician will admit that a diagnosis may remain
doubtful for months and years, and often is disclosed only on
autopsy."" If nerve stretching which, during the past few
years, has so frequently been undertaken by prominent sur-
geons for the cure of tabes, has been followed by brilliant
results,^ mechanical treatment can surely not be prejudicial, nor
would the danger of mistaking myalgia for neuralgia, which
might occur to the best diagnostician, militate in the least
against the employment of mechano-therapy.

According to Senator, many forms of muscular rheumatism
are evidently the result, not of an inflammation, but of a dis-
turbed innervation, either of the muscle itself or its aponeu-
roses. This is evident when muscles are attacked which
from being superficial — as the sterno-cleido-mastoid, for in-
stance — can readily be examined. He adds, that the confusion
already existing on this subject is only increased by including
these forms among those already admitted. Myalgia is often
confounded with those ill-defined neuralgias occurring often in
deep-lying nerves, where the pain, instead of following the
course of the main trunk, radiates over a considerable adjacent
area. The physician, therefore (who, after all, sets more store
on curing his patient than on making fine differential diag-
noses), may confidently proceed to treatment, and with all the
more assurance of success the more evident it becomes that the
painful disease, regarding whose exact nature he still may be
in doubt, is deeply situated in the muscles themselves.

As in neuralgia, so too in myalgia, more or less profound

^ It Ib, perhaps, needless to remark that the efficacy of nerve stretching for tabes is, at the present
time (1887), to say the least, very much doubted by the majority. —Teans.

NEURALGIAS AND MUSCULAR RHEUMATISM. 108

nutritive changes occur, and though we may, at present, be
unaware of the nature of these changes, yet their existence is
denied by none. No means is so potent in removing this con-
dition, especially in muscles, as movement, and hence nothing
can be more injurious in neuralgia, as well as myalgia, as the
frequently recommended rest of the part affected. Tp Bene-
dikt^ belongs the credit of giving (in 1864) a fresh impetus to
the therapeutic value of health gymnastics. In connection
with neuralgic affections of muscles and tendons, he calls
attention to the well-known fact that, generally as the result
of cold or injury, pains may exist for years, seriously impair-
ing the functions of the parts involved, and yet without the
presence of any objective signs. In these cases there can
scarcely be any doubt that local disturbances of circulation
exist in the organs themselves, or in the terminal nerve-supply.

“ The routine treatment by antiphlogistics and absolute rest
only too often fails. Household remedies have in these cases
stolen many a march on science, and, by applying first stimu-
lating poultices, and then employing motion, especially in the
chronic stage, have achieved wonderful success. The labors of
those who have sought to introduce health gymnastics are
soon forgotten, and it is only through the works of Stromeyer
and Volkmann that this form of treatment has again been
systematized. The chief thing in these cases is to test care-
fully both methods of cure at the proper time, and then
consistently to employ the best.”

In neuralgias resulting from anaemia, hysteria, and malaria,
mechano-therapy can exert only favorable influences, for the
passive and active movements employed increase the oxidizing
powers of the blood, and consequently improve the nutrition
of the brain and spinal cord, and the organism generally.

In cases where neuralgia is determined by organic changes,
such as result, for instance, from bone disease, tumors, inacces-
sible cicatrices, senile or other degenerative tissue metamor-
phoses, etc., mechanical treatment will naturally be followed
by the same want of success as other therapeutic measures.
It is necessary, therefore, for the proof of the absolute useless-

1 Benedikt : Nervenpathologie und Elektrotherapie. Leipzig, 1874.

104 TREATMENT OF DISEASES BY MECHANO- THERAPY.

ness of the mechanical treatment of these cases, that as cor-
rect a diagnosis as possible be previously made.

Mechano-therapy of Sciatic and Crural Neuralgia.

As the greater number of sciaticas which have come under
my notice have been combined with crural neuralgia as well, I
think it best to consider these two conditions together. It
seems advisable, also, to discuss the treatment according to a
plan which may, with suitable modifications, be applied to
each special case, and yet one which will embrace the details
gleaned from numerous observations. Let us take a case. A
patient suffering from well-marked sciatic and crural neuralgia
of the right side applies for relief, after having been under
treatment by others for many years in vain. He has used
veratria, aconite, and belladonna ointments, morphine injec-
tions, electricity, sinapisms, and vesicants. We may assume,
also, that for a considerable period he took arsenic, quinine,
and potassium iodide and bromide, that he has been to a num-
ber of springs like Grastein, Wiesbaden, Teplitz, and Eagaz,
and also that neither sea-bathing nor hydrotherapy has had
any effect upon his obstinate malady. He is only able to
drag himself painfully along by the use of a cane, and every
step causes acute suffering. Rising and sitting down can only
be accomplished by aid of the arms, while for going up stairs
or getting out of bed the assistance of an attendant is necessary.
He is never entirely free from pain, and there is generally a
daily exacerbation lasting often several hours and preventing
much needed rest.

Examination shows no other functional disturbances.
There is great sensitiveness in the buttock, at the point of exit
of the sciatic nerve, and* many painful points exist along the
outer and inner aspects of the thigh. The limb, furthermore,
will be seen to be held in a characteristically pathognomonic
position, namely, the thigh rotated inward and adducted, the
knee slightly bent, and the foot not resting on the ground
with the sole, but touching it with the toe only.

On sitting down, the patient supports himself by his left arm,
and lets himself fall, as it were, upon his left buttock, instead

SCIATICA AND CRUBAL NEURALGIA.

106

of performing the usual movements of flexion with knees and
hips. The involvement of the semitendinosus and semimem-
branosus muscles causes great sensitiveness to pressure over
their tendons. Voluntary abduction of the aflfected thigh is
impossible, and abduction of even the well extremity cannot be
performed on standing erect, on account of inability of the
patient to support himself upon the affected limb. External
rotation is also impossible. Hence it appears that the glutei,
the pyriformis, the internal obturator, and the gemelli (external
rotators), are all affected. Hor can the patient flex the thigh
(involvement of the iliac and psoas major), nor can he adduct
it after it has once been passively abducted (involvement of the
sartorius, internal rectus, adductors longus, brevis and magnus,
and pectin eus). But the greatest pain of all is caused by
rotating the thigh outward, as the sciatic is thus made to glide
upon, and rub against the quadratus femoris.

I have purposely selected a case in which all the muscles of
the buttock, about the hip-joint, and of the thigh have become
involved, and hence almost entirely deprived of function.
Many years of experience, and many trials, have convinced me
that the cur^ of these forms of sciatica will be most rapidly
effected when, in addition to the mechanical interferences,
passive and active motions of all the affected muscles are em-
ployed. It has also seemed to me best to begin the daily
treatment with the passive and active movements, leaving the
mechanical manipulations, which are very painful, till the last.
They cause so much exhaustion, as a rule, that the patient is
anxious only for rest, and will hardly have the energy neces-
sary for performing acts which he knows must only increase
his suffering.

First Day of Treatment — It should always be our endeavor
to begin treatment with the simplest procedures, and to grad-
ually advance to the more complicated ones. The simplest and
easiest muscle-exercise for the patient will generally consist in
flexing the thigh. As a rule, I found great difficulty in per-
suading patients to raise the thigh themselves even ever so little.
It is better, therefore, to set a verj^ moderate limit to the distance
the patient is to lift his foot from the ground. Many observa-
tions have convinced me, too, that although there is sufficient

108 TBEATMBNT OF DISEASES BY MECHAKO-THER APT.

muscular power to raise the limb, and though the patients are
gladly willing to bear the accompanying pain, still, owing to
years of functional disuse, the cerebral power of causing the
requisite contractions has actually been lost. I had long been
of opinion that for the restoration of lost muscular function it
is just as necessary to practise upon the cerebral as upon the
muscular apparatus of the patient. This conclusion I had
arrived at even before I could satisfy myself regarding a scien-
tific explanation for it. An explanation, however, is fully
aflibrded by Du Bois-Reymond’s hypothesis, alreadj^ considered,
namely, that muscle exercise is, in reality, brain exercise.

The localization of the cerebral centres of certain of the
special senses has long been known ; but those of many of the
higher functions, as speech, for instance, have only been de-
termined more recently. Between the brain and muscular
movements an intimate relationship must certainly exist, so
that long-continued suspension of the muscular action of any
limb must cause atrophy of the corresponding cerebral area.
A most interesting case in point has very recently been re-
ported, and deserves repetition here.

In 1882, Reymond^ performed an autopsy upon a man, aged
thirty-one, dying of tuberculosis in the Hotel Dieu in Paris.
In J870, the patient had had his left arm amputated, and had
also lost the index and middle fingers of his left hand. The
case was used by Reymond to determine what influence upon
the motor tracts of brain and cord, the loss of function caused
by the absent members could have had. No macroscopic
changes in the cord could be discovered. In the brain, how-
ever, a difterence between the two hemispheres was at once
noticeable. The convolutions in the motor areas of the left
side were perfectly normal, while the right ascending frontal
and parietal convolutions were flattened, sunken, and atro-
phied, their volume being four-fifths smaller than those of the
left side. All other parts of the brain were normal.

The simple form of horizontal bar, here figured, will be
found to answer all purposes. It should be so constructed
that the bar gh, resting on the pegs ik^ can be placed closer to

1 Beymoud : ProgriiB medical, 1882, No. 24.

SCIATICA AND CEUBAL NEUBALGIA. 107

the floor than is the case with ordinary horizontal bars, and
the uprights should be firmly braced by supports.

Fig. 30.

The patient stands in front of the bar (which should be
placed at the lowest hole, about twenty centimetres [eight
inches] from the floor), the physician being opposite and giving
his hands for support. The affected limb is then to be raised
at the word of command, and the foot placed upon the bar.
Although supported, the patient will often be unable to obey.
He should then be directed to steady himself by grasping an
upright with either hand, while the physician, raising the limb,
places the foot upon the bar. After being left thus for from
one to three minutes, the command to put the foot on the floor

108 TBBATMENT OF DISEASES BY MECHANO- THERAPY.

again should be given, but even this motion — intended to act
upon the gluteus maximus — may be impossible, in which case
the limb must again be raised by the operator and the foot re-
placed upon the ground. This passive motion of raising
and lowering the limb should be repeated ten times, it being
left to the physician’s judgment how rapidly it should be
performed, how high the leg should be raised, how long the
foot should remain, and how forcibly it should be placed on
the bar in order to get the best effects of the resulting concus-
sion of the muscles and nerves of the thigh and buttock. The
patient can never be injured by too much exercise. On the
contrary, the duration of treatment will be shortened by
proceeding vigorously. Nevertheless, personal peculiarities
must always be taken into account. Some will prefer to have
the time shortened even though they suffer more in conse-
quence, while others elect a form of treatment which, although
less painful, necessarily occupies longer time. It often requires
no little experience and knowledge of human nature to decide
upon exactly the right thing.

I feel impelled to allude once more to the advantages which
may be gained from the horizontal bar as a means of stimulat-
ing muscular energy that may have been lying dormant even
for years. Many patients, as before stated, even in spite
of every effort, are unable to raise a foot from the ground.
When, however, they are ordered by the physician to place
one foot on the bar (which should be placed as low as possible)
it will be found that they will often succeed, even without help.
It will be noticed that the patient, in raising his foot does so
hastily, seeking to aid the motion by leaning forward, his eyes
meanwhile being kept fixed upon the bar. It will not be pos-
sible, however, for him to maintain this position, for the glutei
are being called upon to fix the pelvis upon the heads of the
femora and to keep the trunk upright, which in their enfeebled
condition they are unable to do. Hence, if no assistance be
offered to the patient, he will either fall, or seek to prevent
this by grasping the uprights, or by throwing the body back-
ward and to the left to bring its weight upon the sound limb.
The significance of the latter position should be well under-

SCIATICA AND CBURAL NEURALGIA.

109

stood, in order not to fall into the error of supposing the
patient now able to stand on both legs.

When this first difficult exercise has been completed passive
motions, and finally mechanical manipulation, maybe resorted
to. For the latter a special bench, which any carpenter can
make, should be used.

Fig. 31.

The seat consists of three adjustable sections, so Joined by
hinges that section a c can be lowered, while sections a b and bd
may be raised ; each section being held fixed at any desired
angle by ratchets placed as shown in the cut. The seat must
be covered by a similar sectional hair mattress, made about
eight centimetres [three inches] thick.

The seat having been made plane to begin with, the patient
lies at full length on his back upon it and executes on the first
day those motions which were previously performed standing.
Then the passive exercises (raising the thigh) are undertaken
by the attendant, the right leg (it is a case of right-sided sciatica
we are supposed to be treating) being grasped in both hands,
and the thigh flexed upon the pelvis, so that the knee is
brought toward the chest. At first the maximum amount of
flexion should not be attempted, owing to the intolerable pain
it would cause. Altogether, it will be well to observe much
gentleness in the beginning, as too vigorous methods, by cans-

110 TREATMENT OF DISEASES BY MECHANO-THEBAP Y.

ing the patient great pain, tend to destroy his confidence in the
physician, and to deter him from proceeding with further
treatment.

When the patient raises the thigh the iliacus and psoas
magnus contract. When passive motion is used, on the other
hand, these muscles remain relaxed, while the sciatic nerve is
stretched in proportion as the knee is made to approach the
chest. Stretching the sciatic, without laying bare the nerve,
has been frequently attempted of late with varying success.
The operation, which is performed during anaesthesia, consists
in producing the maximum amount of flexion of the thigh
upon the trunk — until the dorsum of the foot touches the
patient’s face.

On the first day of treatment the angle of forced flexion
must not exceed sixty to forty-five degrees, and the thigh
should be kept in this position for a moment only, and then
extended again. The manipulation should be performed
slowly and quietly, and with little expenditure of force.

I have occasionally treated cases in which the muscles of the
inner side of the thigh were those most sensitive to handling,
showing that the muscles supplied by the anterior crural nerve,
(psoas magnus and iliacus) were even more affected than those
supplied by the sciatic.

I always repeat each passive motion ten times, directing the
patient to count with me, and although the latter observance
may on first considerations seem a little childish, yet it will be
found, by diverting his attention from himself, to serve a very
useful end, for you may be very sure he will keep accurate
tally to see that the promised ten rounds of pain are not
exceeded, and the moral effect, which the assurance that as ten
is counted his tortures will be over, has upon the mind, far
exceeds any personal influence which the physician can pos-
sibly bring to bear. Indeed, the patient often feels a pride
in completing the magic number, ten, in spite of sufferings,
generally heroically concealed, and often denied. The physi-
cian should always keep in mind how much of his success
depends on tact, perseverance, and moral influence.

The passive exercises having been completed, mechanical
ones may be next attempted, for the first day of treatment

SCIATICA AND CBUEAL NEUEALGIA.

Ill

serves as a sort of general introduction, and to accustom the
painful parts to the touch of the manipulator’s hand. It will
be enough for a beginning to knead gently over all the
muscles of the thigh and buttock as high up as the origins of
the glutei, and along the crest of the ilium (where the glutei
are generally most sensitive), using the tips of the first, second,
and third fingers, as shown in Fig. 3. As each part should
be gone over at least ten times, the whole procedure will take
from eight to ten minutes, and it is best when halfway through
to give the patient a rest of two or three minutes. This he
should also have between the active, passive, and mechanical
exercises.

The physician must not allow any expressions of pain on the
part of the patient to alter his original programme. Should
the patient not possess enough moral courage to observe the
necessary quiet, he must, if necessary, be held ; if possible, by
some member of the family possessed of the requisite authority
and force, rather than by an attendant of the physician.

The pauses between the various kinds of treatment may be
used to seek to influence the disease by lying upon the bench
in certain favorable attitudes. (See Fig. 32.)

Fio. 32.

The foot-piece should be lowered, allowing the legs to hang
over the edge, and thus exerting a gentle traction upon the
muscles connecting the pelvis with the thighs and legs. These
muscles, hitherto inactive, will in this way receive a certain

112 TREATMENT OF DISEASES BY MECH AN 0 - THERAPY.

amount of stimulation by their nerves being slightly stretched
(which may cause some pain).

The patient should wear a costume such as has been
described. Inunction is unnecessary.

The above manipulations complete the first day^s treatment,
at the end of which the patient will generally complain of
much pain and fatigue. Sometimes a rise from 0.5° to 1° C.
in temperature can be noted, accompanied by increased rapidity
of the pulse. The pain, which during the active manipulation
may have been very severe, usually diminishes considerably in
about half an hour; occasionally, however, lasting for hours
after. In the beginning, too, the nights — always dreaded by
sciatica suflierers as the time when painful attacks are most
frequent — may be even more broken than before. The physi-
cian should warn the patient of this, lest in alarm he be
deterred from proceeding with the treatment. In six to twelve
days usually a change for the better occurs, the nights become
more tranquil, the pain is less, and the first signs of approach-
ing convalescence begin to appear.

Second Bay of Treatment — It is almost a matter of course
that the physician will be confronted with every kind of doubt
on the part of the patient, regarding the ultimate results of
treatment, but as failures are rare where sufficient perseverance
and the requisite skill have been employ ed, he may confidently
combat these misapprehensions.

Programme for the day. 1. Repetition of yesterday’s exer-
cises at the horizontal bar (thigh-lifting, ten times), placed at
same height as before.

(The patient will rarely be more successful than on the pre-
vious day. Should active motions be impossible, the passive
form, executed by the physician, will be required. Should,
on the other hand, the patient be more successful than before,
the bar may be raised to the second hole and the exercise
repeated.)

2. New exercises, involving the abductors and adductors of
the thigh (the glutei, the gracilis, the adductores longus, brevis,
and magnus, and the pectineus).

Order the patient first to abduct and then adduct the aflected
limb. This, like lifting the thigh, may be done either while

SCIATICA AND CEUKAL NEURALGIA.

113

standing or Ijing. At first sight, it might seem as though
it could be more easily performed lying down, because in the
erect position the glutei are obliged not only to abduct the
thigh, but to maintain the trunk upright on the heads of the
femora. Experience, however, sho^vs the opposite to be true.
If adduction be attempted while standing, it will be noticed
that the patient first transfers the weight of the trunk to the
sound side by leaning in that direction, and at the same
moment, while balancing himself with the arm of the affected
side, he allows the limb rather to fall outw^ard by its own
weight than to adduct it by any actual contraction of the
aflfected muscles. When lying on the back, however, the
motion can only be performed by means of the glutei. In
the beginning, imperfectly performed exercises must often be
allowed to suffice. A certain amount of participation by the
disabled muscles must occur, however much the sufferer may
seek to avoid it, and try, in spite of every longing for a cure,
to deceive both the physician and himself.

If, in spite of every efiFort, independent attempts at abduction
and adduction should fail, the physician standing opposite the
patient should support him by grasping both hands in his.
Should this aid still be insufficient, he must be directed to
steady himself with both hands at the uprights of the hori-
zontal bar w^hile the movement is performed passively the
usual ten times. After this, active and passive flexion, ab-
duction and adduction, performed lying upon the bench,
should follow. It may be well to remark here that these
motions can often be more easily accomplished if performed
simultaneously with the sound limb. The pauses should be
used to allow the patient to lie with his legs over the end of
the bench upon the depressed foot-piece, as before alluded to,
in order to exert traction upon the affected muscles. At first
the angle should not exceed 135 degrees, but little by little it
may be diminished, until finally the legs hang at right angles.
Traction may be still further increased by placing the head-
piece of the bench at an angle to the middle section (Pig. 32).
In this position the pelvic muscles are put upon the stretch,
and the greater the inclination of the sections to each other,
the greater the amount of extension.

114 TBEATMENT OF DISEASES BY MECHANO- THERAPY.

Mechanical manipulations should now follow, beginning
with the same kneading as yesterday, only executed some-
what more vigorously. Mild pinching also may now be intro-
duced (see Figs. 14 and 15). For the physician this is one of
the most tiring of all the manipulations, especially when per-
formed upon muscular or corpulent individuals. For the
regions of the buttocks, the outside, front and inside of the
thigh, I commonly use both hands conjointly placed side by
side. As this particular manipulation — whose object it is to
reach the deep-lying muscular layers — is an extremely painful
one for the patient, it may be necessary, during its perform-
ance, for an assistant to steady the limb upon the bench.

Third Day of Treatment . — To avoid constant repetition, it
may be stated here, once for all, that each day’s programme
always includes the whole of that of the previous day. I
therefore only describe the additions made each day.

The bar being placed at the lowest hole, we order the
patient to raise his foot and place it on the other side of the
bar, and to keep it there from half to one minute before
returning it to its original position. Generally, in the begin-
ning at least, he will need to be supported by the hands.
Should he be unable to accomplish the exercise at all, it will
have to be performed for him (ten times) by the physician,
while he supports himself, as before, by the uprights of the
bar. Kneading with the knuckles, as shown in Fig. 5, is the
additional mechanical manipulation for the day.

Fourth Day of Treatment. — First, placing the sound foot
upon the bar ; secondly, stepping over the bar with the sound
foot.

This exercise involves a decided change in the treatment,
it being easier for the patient to lift the ailing limb for a
moment, than the sound one. For when the affected limb is
raised the body is supported on the sound one, whereas, when
this is raised, the burden of maintaining the body upright falls
upon the affected glutei and all the other muscles connecting
the pelvis with the thigh and leg. Support will generally be
needed.

The new mechanical manipulation consists in “ thrusting ”
the thick muscle layers. (Fig. 7.)

SCIATICA AND CRURAL NEURALGIA.

115

Fifth Day of Treatment — Every second or third day the bar
should, if possible, be raised one hole higher.

New exercise: Sinking the knee upon a cushioned stool,
the right and left alternately, and remaining thus half to one
minute, — first with, later without support.

Passive fiexion of the thigh is to be executed, with daily in-
creasing force, the knee being brought nearer and nearer to
the chest. In extension, the thigh should be, as it were, hurled
upon the bench again with considerable violence, which pro-
duces often a very painful degree of tension in the nerve. At
this period of treatment the patient will, as yet, be unable either
to lie down upon the bench, or to rise from it in a natural
manner. In attempting to lie down he first lies upon the
sound side and then, with help of the leg and arm of that side,
pushes himself toward the middle of the bench, and then rolls
over on his back, the ailing limb, meanwhile, being held in the
characteristic position. It will be noted, too, that while lying
on the bench the right (aflected) buttock is scarcely allowed
to touch the mattress, the body being supported on the left,
and being, consequently, turned somewhat toward the sound
side. It frequently takes from six to eight weeks before the
normal positions assumed in lying, sitting, and standing are
resumed.

Sixth Day of Treatment — First, sinking w’ith the right knee
upon a cushioned foot-stool, and remaining thus. Then the
same motion performed wdth the well knee. This is always
the more painful and difficult exercise of the two for the
patient. Support must be given if necessary.

The patient then lies upon the bench, and a mild form of
muscle hacking (see page 61 ) is used for the first time. Care
must be exercised to avoid striking over bones, as these
are often very sensitive, hence this manipulation cannot be
properly performed by any one ignorant of anatomy. The
manipulator should be perfectly familiar, even on the clothed
body, with the location of all the bones of the hip, thigh, and
leg ; and both in men and women due consideration must be
paid to the genitals, especially since certain muscles, as the psoas,
iliacus, and pectineus, which are inserted into the lesser tro-
chanter and consequently in the immediate neighborhood of

116 TREATMENT OF DISEASES BY MECH ANO - T HE R AP Y.

these organs, are often the seat of obstinate pain. No form of
manipulation is so potent, so far-reaching in its effects as mus-
cle hacking, provided, always the patient is able to endure the
pain. On well-developed individuals it should be performed
with the full power of the arm, and it is not at all
uncommon to find ecchymoses produced in consequence.
These ecchymoses, though often alarming enough to the
patient and his friends, should not influence the physician for
a moment, as they have no bearing either upon the progress or
duration of treatment. On the contrary, they are to be regarded
as rather favorable than otherwise. As in pannus, the inflam-
mation resulting from the use of irritating applications pro-
duces a resorption and clearing up of the thickening and
opacity of the cornea which had perhaps resisted all other
treatment, so old exudations in and about joints may be made
to disappear by the inflammation set up by the straining and
tearing of the parts caused by vigorous mechanical treatment.
In a similar way these hemorrhages produced in the skin, and
no doubt also in the muscular substance, lead to an increased
circulatory activity and metabolism, and hence to a more rapid
removal of those products of tissue disintegration which had
hitherto been retained in the muscles and nerves. At any rate,
I have always noticed that in a few days after the resorption
of the extravasated blood, the exercises were accomplished both
with greater ease and with less pain. The physician should,
however, make it a rule to undertake no species of mechanical
manipulation upon the parts until the pain and discoloration
of the skin, resulting from the ecchymoses, have disappeared,
and it would be well, too, to give warning beforehand of the
probability of their occurrence, in order to guard against
alarm and dissatisfaction on the part of the patient.

Muscle hacking, like all other manipulations, is much facil-
itated by the patient^s assuming a position favorable for its
execution. In some cases the physician will find it best to
stand on the sound side, in others on the affected side. Thus
when the muscles of the inner aspect (iliacus, psoas, adductors,
pectineus, and gracilis) of the thigh are to be hacked, he
must stand on the affected side, beginning the hacking at the
knee carrying it up toward the pubis. The thigh, meantime.

SCIATICA AND CRUEAL NEURALGIA.

117

being slightly abducted, and the knee bent, in order that the
least amount of resistance may be offered to the edge of the
manipulator’s hand. The glutei, the biceps and extensor quad-
riceps cruris — that is, the muscles of the buttock, and of the
back and front of the thigh — can be as conveniently reached
from one side of the patient as from the other. For efficiently
attacking the origins of the semimembranosus and semitendi-
nosus muscles it will be necessary to stand on the affected side,
and the patient must lie prone, with his legs well apart. In
the beginning an assistant is usually required to keep the
well limb drawn to one side. In regions where bone is but
thinly covered with muscle, a very mild form of hacking
must suffice, whereas, where a layer several inches thick inter-
venes much force may be used. Beginning at the crista ilii,
the force employed should be gradually increased as the tuber
ischii is approached; from here downward it should be again
diminished. The same method must be observed in going
from the trochanter to the knee. Attention, too, must be paid
to the horizontal ramus of the pubes.

As muscle hacking is the most painful of all manipulations,
it should always form the close of the day’s treatment.

Seventh Day of Treatment . — Active and passive exercise of the
external and internal rotators.

The best means for the patient to accomplish external rota-
tion is, while standing erect, the heels being close together, to
try and turn the toes out as far as possible. The angle thus
formed will, at first, be small, but it will gradually increase in
size, until finally the feet are almost in a straight line.
For the internal rotators, the opposite exercise is indicated.
The heels being separated, an efibrt is made to turn the
toes out. The knees must be kept straight, for when bent, the
movement of the feet can be accomplished entirely by rotation
of the tibiae.

An exercise combining the use of the rotators and the abduc-
tors and adductors is performed as follows : The patient
standing first with the feet close together, separates the toes
and heels alternately, until the legs are at their maximum de-
gree of separation, when they are to be brought together again

118 TREATMENT OF DISEASES BY MECHANO- THERAPY.

in a similar manner. The muscles of the calf are also neces-
sarily used, but this is no objection.

Passive movements follow next; passive external rotation
being best performed with the patient sitting, as shown in

Fig. 03.

Fig. 33. Downward pressure is then made by the hands
placed upon the knee. This operation is so painful that it
must be begun very gently, and only after a number of days,
usually, is it feasible to increase the amount of force. The
exercise on the bench consists in the physician crossing the
patient’s legs for him.

The order of the mechanical manipulations is not to be
changed from this period until the cure is completed. It is
as follows: First, pressing and kneading (the fist will have
to be used for the more fleshy parts), producing so-called
vibrations. Second, pinching and hacking. The amount of
force used should be increased a little daily. It will be noticed
that the patient’s sensibility usually becomes much less by the
end of the first week, and that the pains begin to decrease.

SCIATICA AND CRURAL NEURALGIA.

119

also that certain motions, hitherto impossible, can now be per-
formed, even though clumsily and with trepidation. Sitting
down, as well as standing perfectly erect, will still be difficult.
The carriage also will be faulty and only in the physician’s
presence does the patient attempt to correct it. When unob-
served, but little change will probably be noticeable. Sleep,
however, is better, and the nocturnal attacks of pain less fre-
quent and severe.

Cases occur, though, in which a week’s treatment makes not
the slightest impression, so far as reducing either the pain or
the disability goes. Indeed, all the symptoms may become
aggravated. This, however, should be no cause for discourage-
ment, and treatment must be consistently persevered in. In
the severer cases, of course, where convalescence is protracted,
the number of mechanical manipulations possible will be small,
while the employment of active motion may be entirely out of the
question. Nevertheless, the labor expended will not be in vain.
It will have been, so to speak, stored up in the muscles, and
it may all at once make itself evident, for after the second or
third week a number of motions will suddenly become possible
in a surprisingly short space of time, the final result of treat-
ment thus remaining the same. From long experience I can
confidently say : Be patient and persevere ! Success will
come at last !

Eighth Day of Treatment , — If everything has gone well , the time
will now have come to attempt some combination movements,
as walking, sitting, lying, straddling, and squatting. The first
lesson to learn will be that of walking properly, — for the
patient from having walked faultily so long will have to learn
the art anew, for he really does not walk at all, — at least not
physiologically. In the physiological walk the body is first
inclined forward ; this shifts its centre of gravity from a point
lying on a line which passes vertically down between the feet,
and we would consequently fall, were this not prevented by
advancing one leg. The feet then rhythmically replace each
other, and although the time in which this alternation occurs
varies from the slowest pace, to the swiftest run, only one
extremity at a time bears the body’s weight. In our
assumed case (right-side sciatica) the patient really walks only

120 TREATMENT OF DISEASES BY MECHANO- THERA? Y.

with the left leg, dragging the ailing one after. For the toes
of the latter will hardly have touched the floor, before the well
leg will have made a step forward, the sufferer, meantime,
transferring the weight of his body to a cane held in the right
hand, so as not to allow the right leg to support the body an
instant. Forcible means are in these cases often the most
successful. The physician should grasp the patient by both
arms and draw him forward. Thus taken by surprise, he will
be compelled to take a step, and thus, with knees and hips
bent, under protestations of pain, or even with tears in his eyes,
he takes his first lesson in walking. Should, however, such
heroic treatment seem inadvisable it will be best to leave the
first attempt to the patient’s own initiative.

By means of a very simple form of apparatus it is often pos-
sible to teach a patient to walk properly in a few days.

Fig. 34.

It will be noticed that he drags the right leg instead of
raising it. Now, to overcome this I had a number of wooden
blocks made — eight to twelve, according to the length of the
room — 1 long, 0.06 thick and 0.12 wide, (39 by 2 ^ by 5
inches). These are placed at regular intervals upon the floor,

SCIATICA AND CRURAL NEURALGIA.

121

and the patient being drawn forward by both hands, is thus
forced to step over the impediments in his way. The rhythm
with which he does this will not be uniform in the beginning,
the affected leg being naturally favored.

This movement is to be repeated ten times, the patient being
always supported to prevent a possible fall, for even if the pain
be overcome and the sole planted squarely on the floor, he still
has no really secure footing as yet, but sways like a reed in the
wind and would certainly fall if left to himself. It is necessary
to impress upon him that he may rely with absolute confidence
upon his assistant, who should closely watch his every move-
ment. It would be a very great error to deprive him, even for
a moment, either through carelessness, or in jest, of this ex-
pected aid, for it would influence all his subsequent progress.

I cannot help reverting here to Du Bois-Keymond’s conception
of the unity existing between muscle and brain exercise. The
patient, though protesting his inability to make a single step,
as soon as he has some definite object before him — in the shape
of overcoming the blocks on the floor — raises his foot, thus in-
voluntarily calculating, in his mind, their height and breadth.

These seemingly insignificant blocks of wood have been
of the greatest service to me. By increasing the distance
between each, by placing them either on their sides or edges,
or by laying one on top of the other, they may be made to
present a considerable variety of gradations. The patient
should be made to walk over them both backwards and for-
wards, at first slowly, then fast, and, finally at the word halt^
to stop, first when the well leg and then when the ailing one
has been put over a block. Only when each command can be
promptly obeyed may we assume that both muscles and brain
have again learnt the art of walking. More difficult than walk-
ing itself, will be to halt for some time just after the affected
leg has stridden over a block, because now this leg will have to
bear the whole weight of the body; on the other hand — from a
similar reason — the affected leg can b6 lifted over the blocks
with greater facility than the vrell one.

The results achieved by means of this simple apparatus do
not, however, become apparent quite so soon as the reader
may have, perhaps, been led to believe. During the first

122 TREATMENT OF DISEASES BY MECHANO- THERAPY.

week or so, efforts at walking are still so painfully and clumsily
performed that one might feel inclined to abandon all further
attempts by this means. It should, however, be persevered
in, for it is often not until the third or fourth week that the
results become evident. Besides, every little progress made
by the patient is watched by him with the greatest interest,
and every newly acquired movement — which may for years
have been impossible — is hailed by the family with the same
delight as that with which they welcome the baby’s first
“ papa ” or ‘‘ mamma,” or his first tooth.

Further exercises consist in a repetition of all previous
active and passive motions on the bench.

New exercises : flexing the lower extremity as a whole, the
knee being extended. This is one of the most difficult of all
the muscle exercises, for in addition to all the flexors of the
thigh, the extensor quadriceps cruris is brought into action as
well.

Ninth Day of Treatment . — The first exercises in seating are
now begun. The patient must try to sit down upon a chair
and rise again without the aid of his arras. A large number
of muscles take part in executing this act, but the glutei
especially are called into play to steady the trunk upon the
heads of the femora. The attendant’s aid will be necessary
at first.

Upon the bench, maximum abduction is performed, the
thighs being so far separated that the legs hang straight down
at the sides of the bench. The weight of the legs stretches
and extends the abductor and flexors of the thighs; a pro-
cedure which is as beneficial to the patient as it is usually
painful.

T'enth Day of Treatment . — The time daily necessary for
treatment (thirty to forty minutes) naturally increases with the
number of exercises performed. Practice in running over the
blocks for the first time, in the beginning assisted by the
physician’s giving his hand in support.

On the bench, the same movement as yesterday, only with
the difference that the extremities are separated violently —
in order to obtain the greatest degree of abduction — and then
at once brought together again.

SCIATICA AND CEURAL NEURALGIA.

123

Eleventh day of treatment is to be observed as a day of entire
rest.

Twelfth Day of Treatment — Since, in running, the body is
supported upon the toes alone, the muscles of the calf are
necessarily forced to bear the weight of the whole body. In
our course of treatment running forms the preliminary exer-
cise to standing upon the horizontal bar. For the latter
exercise to be possible for the patient, not only must the
muscles have by this time gained greatly in power, but
the sensitiveness of the nerves, also, have correspondingly
diminished. Prom the many modifications of which it is
capable, it will aftbrd employment for many days.

In the beginning, we put the bar at the lowest hole, and
then raise it one hole every day — or every second or third day,
according to circumstances.

1. The patient, supporting himself by the uprights, steps
upon the bar first with the well and then with the ailing leg,
drawing the other after him, and then standing erect. 2. Put-
ting one foot on the bar, he steps over it with the other,
remains for a moment in this position, and then stepping back
again. 3. With his back to the bar he raises himself alter-
nately with the well and with the ailing leg, to the erect posi-
tion, either staying in this position or stepping down backward
with one foot, while the other remains on the bar. The
execution of these diflPerent modifications, of which only one
a day should be undertaken, will occupy five days at least.

For exercising the abductors, the patient is to set straddling
on a chair.

On the bench, “ thrusting ” of the thigh while completely
flexed, is to be performed.

Thirteenth to Twentieth Day of Treatment — Repetition of all
the different modifications of stepping on and over the bar.
Sitting exercises (generally very hard for the patient). Repe-
tition of all previous bench exercises.

Walking, running and kneeling exercises (kneeling first on
a chair, then on a stool, and then on a cushion on the floor,
and rising again, first with, then without assistance).

For the close of the daily programme, all the different
mechanical manipulations.

124 TREATMENT OF DISEASES BY MECHANO- THERAPY.

Twenty-first Day of Treatment . — Second period of rest.

Twenty-second Day of Treatment . — On this da}’ the execution
of a combination-movement — as crossing the legs — is to be
undertaken. These kinds of movements are the most difficult
of all for the patient to perform.

The old idea, that the act of crossing the legs was per-
formed by the sartorius muscle has been shown by Hyrtl to be
erroneous. Both in the lying and sitting positions, it can
only be brought about by the consentaneous action of the
flexors and adductors of the thighs, and of the flexors of the
leg. In accordance with Du Bois-Reymond’s theories, com-
bination movements (as the use of some tool, or of a knife
and fork, etc.) require longer practice than simple movements,
since the various degrees of contraction and relaxation must
all be made to harmonize exactly. It is true that the act of
crossing the legs, when compared to that of using a needle,
requires but a low degree of dexterity; nevertheless it involves
the successive or simultaneous contractions of at least three
different groups of muscles. Even when after practice the
long-forgotten movements of flexion and adduction of thigh
and flexion of the leg, have once more been learned, the
facility for successfully combining these motions may still be
lacking.

Crossing the legs is more easily performed in the lying than
in the sitting posture, because, when lying, the patient requires
less force to flex the thighs. Nevertheless, it will still prove
a slow and difficult operation, and the difficulties in the way
of executing the necessary mental processes become very
obvious. In nearly all the cases of chronic sciatica which I
have treated, I have found this the very last movement to
be correctly executed, requiring often three to four weeks’
practice. In a few cases I have noted that the ability to per-
form it did not, as usual, become perfected gradually,
though the patients gave themselves the greatest trouble for
weeks to learn it. One tine day, however, when crossing the
legs had to be performed as one of the regular exercises, they
were able to execute it almost perfectly. The volitional im-
pulse had, in these cases, been exerted for weeks, only the
muscles had not comprehended it. All the other exercises,

SCIATICA AND CRUEAL NEURALGIA.

125

however, had in the meantime been learned, all their various
stages, from the most painful helplessness to faultless perfec-
tion, having been gone through.^ In the beginning, crossing
the legs must be performed passively, the patient both lying
and sitting.

Twenty-third Day of Treatment — The time will now have
come to put the strengthened muscles and nerves to the
final trial of their capabilities. This will consist in testing
their ability to perform the act of leaping.

This act may be executed in every variety of gradation, as
follows:

1. The patient (whose hands are grasped by the physician’s
for support) jumps with legs pressed close together, down
from the horizontal bar placed at the lowest hole. The pain
caused by the inevitable jar will be severe, and it requires
considerable fortitude on the part of a patient with sciatica
to undertake this act. The physician will be obliged to watch
the patient’s feet closely, for even the most conscientious
patient will seek to catch the brunt of the body’s weight upon
the sound foot alone. The position of the feet may, at the same
time, be so nearly physiologically correct that it requires a
very practised* eye to detect the deception. When the patient’s
attention is called to his delinquencies he readily admits them,
and will generally strive to bear the necessary pain.

2. The patient performs abduction and adduction while in
the act of leaping. The effort necessary for the upward
spring serves to intensify the effects of these motions.

4. The patient, keeping the legs close together, jumps over
the bar placed at first at the bottom hole, and gradually raised.

By raising the bar Nos. 1 and 3 may be modified. At first,
a mattress should be placed to jump upon, and at all times the
physician should be on hand to render assistance if necessary.

Twenty-fourth to Thirtieth Day of Treatment — Repetition of
all previous exercises.

Thirty-first Day of Treatment. — Day of rest.

1 The translator would hero recall his own analogous experience in trying to master a bicycle.
For a week not the slightest progress was made. 1 was not able to stay on the machine for a single
revolution of the wheel. Then on attempting it again one day, all of a sudden, I was able to ride
any distance I might have chosen, apparently, without any effort — W. M.

126 TREATMENT OP DISEASES BY MECHANO- THERAPY.

Thirty-second Day of Treatment — By this time the cane,
which was for so many years the patient’s trusty companion,
will have been discarded, and going up and down stairs (the
latter being always the more fatiguing) will now be possible
without assistance. He will now be able, too, to kneel, or
even to leap. Most of these actions are performed without
any pain whatever, while in some there is still a certain amount
of both awkwardness and pain.

Nocturnal pain has gone entirely, and in consequence sleep
becomes natural once more.

The motions which will still be difficult and painful, are
those of squatting, and of turning while lying.

During the act of squatting, with heels together and knees
turned out, the maximum power of all the muscles of the lower
extremities and pelvis is called upon. The external rotators of
the thighs, with the gastrocnemius and soleus muscles, are in
a state of active contraction, while the extensors, quadriceps
crurorum, and the adductors are passively put upon the stretch.
In addition, the glutei fix the pelvis upon the femora. To hop
backward and forward, while in this position, is a pretty difli-
cult feat even for perfectly healthy muscles and nerves, and its
performance, therefore, in addition to the ability to cross the
knees with readiness, may be regarded as the evidence of a
perfect cure. In old people such result should be looked for,
and the movement should not even be attempted.

The movement of turning over while lying is always per-
formed by the patient in the direction toward the well side,
and with the help of the arms, the ailing limb remaining
inactive. Similarly it will be seen that it is upon the sound
side that he lies, both when assuming the recumbent posture
upon the bench, and when quitting it again. We therefore
seek to force him to use the affected side in these actions instead
of the well one, and the acquirement and practice of the neces-
sary exercises will, therefore, occupy the balance of the curri-
culum of treatment, which may last in all from six to eight
weeks. Meanwhile, the mechanical manipulations must be
continued, until not a trace of sensitiveness remains. During
the last few weeks, it will generally be suflScient to practise
with the patient, who may now be fairly regarded as convales-

GENERAL OBSERVATIONS.

127

cent, every second, third, or fourth day. Only when all the
exercises can be faultlessly executed can he be discharged as
perfectly cured.

General Observations.

The line of treatment which we have been considering
is, of course, only intended to serve as a general scheme,
which will have to be specially modified for each case. If,
for instance, instead of all, only certain muscles of the hip
and thigh are aftected, only such exercises as involve their
use need be employed, and mechanical manipulations must
similarly be directed chiefly to those portions most sensitive to
pressure. It may be adopted as a good working rule that the
difficult and painful exercises are the ones which ought most
to be practised.

The duration of the treatment will depend on various
factors :

1. On the previous length of the illness.

The longer the disease has existed, the more protracted will
have to be the treatment. Eight weeks will, as a rule, be the
limit, — at lea^t that was the time needed to cure one of my cases,
of a previous four years’ duration. Cases of only a few months’
standing often need but ten or twelve days for a cure. No
fixed time, however, can possibly be laid down, for it may
happen that a recent sciatica will take twice as long to cure
as an old one.

2. On the extent of the disease.

The greater the number of muscles involved, the more nu-
merous must the number of corresponding exercises be, and
hence the longer the time required. However, this rule, too,
has many exceptions, extensive neuralgias being sometimes
cured in a short time, while localized ones may tax to the
utmost the patience of both physician and patient.

3. On idiosyncrasy.

In sensitive individuals it is often necessary to proceed very
cautiously and gently at first. More time is therefore required
in these cases than where the patient is not of a timorous or
complaining disposition.

128 EXERCISES OTHER THAN THOSE PRESCRIBED.

4. On the skill, the experience, and the perseverance of the
physician.

Familiarity with the methods frequently enables a practised
hand to employ many devices which an inexperienced person
very properly avoids, just as boldness in an old surgeon is more
justifiable than in a young one.

5. On the age and general nutrition of the patient.

• These two factors affect the results of mechano-therapy in
the same degree as they do all other forms of treatment. In
old and degenerate subjects, the changes in the muscles and
nerves, w’hich we seek to bring about by mechanical means,
are, of course, more difl[icult to effect than in the young, yet
I have often treated patients over sixty with the very best of
success.

ON THE ADVISABILITY OF PATIENTS UNDERTAKING
EXERCISES OTHER THAN THOSE PRESCRIBED
BY THE PHYSICIAN.

This a question which, very frequently, will be raised by the
patient himself. I have, however, come to the conclusion that
it is best not to undertake any independent therapeutic exer-
cises. For, in the first place, their repetition could only be of
use if performed within the succeeding twenty-four hours, and
few patients have moral epurage enough to go through the
necessary pain without the stimulus of encouragement from
the physician. Then, too, they are very apt to be performed
in a bungling and incomplete manner.

Mechanical manipulations should not be performed oftener
than once a day. On the other hand, the patient can contribute
greatly toward his own cure by striving, as soon as he is at
all able, to observe and correct all faulty movements of such
various acts as walking, sitting, lying down, rising, or going up
and down stairs, etc. Yet, in spite of all, it will be seen how
quickly reversion to the faulty carriage, which has become the
habit of years, takes place as soon as his attention is diverted
from himself. I have often noticed how such patients, when
reminded, would go up stairs quite correctly — that is, placing
one foot after the other on succeeding steps — but that as soon
as their attention had been diverted by conversation, and the

OASES.

129

will-power thus withdrawn from the affected muscles, they
unconsciously fell into the old way of putting the well foot
upon a step and drawing the ailing one after. In these cases,
those surrounding the patient can be of much use by constantly
reminding him of his faulty movements.

The same remarks hold good of sitting and rising. In sitting
down both thighs must be flexed, and both buttocks touch the
chair simultaneously, and the patient must not, as has been his
custom, let himself down upon the sound side with the assist-
ance of his arms. In rising also, the weight must be borne
upon the affected limb.

The various cutaneous hA^persesthesias and anaesthesias, so
frequently accompanying sciatica, invariably disappear under
mechanical treatment, and the intensification, which often
occurs in the beginning, need cause the physician no anxiety.

Cases.

Although all cases of sciatica have many features in com-
mon, nevertheless each will have its peculiar points of interest.
I here present two — as types, of the unilateral and bilateral
forms.

Case I. Unilateral Sciatica.— Baroness L. C., aged nine-
teen. In December, 1876, had scarlatina, followed by neu-
ralgia in the left arm and cheek, and in the right lower
extremity. Since then, though strong and hearty, had con-
tinued to suffer continuously from tearing, boring pains. In
the autumn of 1877 walking became impossible. Prof. Knoll,
one of the most distinguished clinicians of the University of
Prague, who was at that time treating the patient, since told
me that there then existed, besides left mental and cervico-
brachial neuralgias, an area of pain corresponding to the
region supplied by the right sciatic nerve, though not entirely
confined to its distribution. The strictly localized neuralgias
yielded very quickly to galvanism. The pains in the right
leg, however, in spite of electrical treatment, both with the
constant and interrupted currents, obstinately continued
through the whole winter, till April, 1878. During the sum-

130

CASES,

mer of 1878, the patient took thirty-six mud-baths at Elster,
without any effect, nor did the electrization of the limb by
Dr. Lober, the local physician, do her any good. In the win-
ter of 1878 and 1879, Prof. Knoll again employed galvanism,
but in vain.

During the summer of 1879, by her physician’s advice, she
drank Schwalbach water, and later went to Gastein, where
she took twenty-eight baths. These seemed to benefit her, for
whereas when she first came she had to be wheeled in a chair,
she needed only a cane on going away. The pains, however,
were as bad as ever; indeed, they had increased both in
severity and constancy, until by October, 1879, she was scarcely
a moment free from them. Paroxysmal attacks, also, lasting
from seven till twelve o’clock p. m,, made their appearance,
robbing the patient of much sleep. The limb naturally
became more and more incapable of use the less it was used ;
and finally it came to such a pass that she could not be induced
to go to bed for months at a time, but would pass her nights
upon a sofa or in an arm-chair.

It was while in this condition that the lady came to me. She
could then only walk by the aid of a cane, and in going up
stairs dragged the affected leg.

Treatment was begun December 13. 1879, and on February
2d, following, she was discharged cured. Before leaving she
took part in a dance, a thing she had not done in years, and
no one present was able to detect in any of her attitudes or
movements a trace of her former trouble.

The plan of treatment described above was essentially the
one followed in this case, without any interruption. On one
occasion only, however, both the patient and I were threatened
with having to abandon treatment, in consequence of extensive
ecchymoses being produced from kneading and hacking the
muscles of the buttocks and of the inside and outside of the
thigh. This occurrence greatly alarmed both the patient and
her friends, but a few reassuring words soon set matters right.

It was fortunate that the patient had been entrusted to the
care of her aunt, the countess L., a sensible, energetic woman,
who assured me that so painful a course of treatment would

CASES.

131

never have been allowed at home, and that at the sight of
the ecchymoses an end would have been put to it at once.
And I take this occasion to say that many failures laid at the
door of mechano-therapy are more rightly to be attributed
either to want of perseverance on the part of the patients
themselves or their families, or to lack of self-confidence on
the part of the physician.

Case II. Bilateral Sciatica. — Before detailing this inter-
esting case I may be allowed to preface it with a few explan-
atory remarks.

I passed the winter of 1880-81 in Paris, and as I had
already for some years devoted myself to mechano-therapy, it
was but natural that I should be specially interested in study-
ing it in the great centre of French medical science. But so
far as I could see, none of the attendants of the Paris hospitals
or clinics employed mechano-therapy at that time.

Happening at one time to be at the Hopital Necker, Prof.
Blachez, the attending physician, invited me to make morning
rounds with him. Upon coming to a patient lying upon his
belly. Dr. Blachez said to me :

“ What would you do in Vienna for a patient with sciatica,
upon whom all previous treatment has been of no avail

“We would treat the case mechanically,’’ I replied, “using
both passive and active movements.”

“Very well, the young man is at your disposal,” the chief
of the division replied, with a rather incredulous expression
upon his face.

Of course, I was exceedingly glad to have this chance of
visibly demonstrating in Paris itself the utility of the mechan-
ical methods, for with few exceptions members of the profes-
sion there regarded the whole system either with dislike or
inditierence.

Eugene Mangeant, twenty-three years old ; mason. In
January, 1881, brought to Hopital Necker, suflfering from
subacute rheumatic arthritis of the left knee and ankle,
with moderate effusion into those joints. One year before had
suffered pains along the shins extending up into the thighs.
He dates his present trouble back to the winter of 1880, when.

132

CASES.

after sleeping one night in a cold, damp room, he awoke next
morning with pains in both legs. After the usual treatment
the arthritic trouble disappeared, but there remained a bilateral
sciatica (worse on the left side), which has resisted all kinds
of treatment for the last two months and a half.

Examination shows numerous painful points on the but-
tocks and thighs, sensibility being especially acute on the
nates at the emergence of the sciatic nerves, and along the
crest of the ilium (origin of the gluteus maximus) and also at
both tubera ischii. The left popliteal space is also very sensi-
tive.

The pains, which have not changed their location for
months, are most severe at night, but are never wholly absent.
At three o’clock every morning they awaken him, and only
gradually diminish about seven. Sleep is only possible in
the prone position. As soon as awakened by the pains, he
turns with difficulty upon his back by the aid of his arms,
lying rolled partly toward one side, touching the bed with the
right buttock alone, this being the less sensitive of the two.
The left thigh is abducted, the left knee flexed, and resting
partly upon the right one.

The patient is well nourished, and all functions are per-
formed satisfactorily with the exception of micturition, at
which he has to strain five to eight minutes before the stream
can be started. The urethra being normal, there undoubtedly
exists a paretic condition of the vesical muscles, easily ex-
plained through the anastomoses existing between the sacral
plexus (which gives off the sciatic), and the hypogastric plexus,
which sends branches to the bladder.

Walking and sitting are both impossible. Each thigh has
extensive anaesthetic areas on the anterior and external
aspects, reaching from the trochanters down as far as the mid-
dle of the calf. The prick of a needle, even when thrust its
whole length into the part, is not felt.

To leave his bed — which he can only do with great pain —
he raises himself with both arms and cautiously lowers his
body as though it were a log. When placed seated upon a
chair he rests upon the right buttock only. When an effort

CASES.

133

to walk is made — which costs him the greatest exertion and
pain — no active motion at the left hip-joint occurs at all.

I will omit the details of the exercises performed, as they
were essentially the same as those used in Case I., contenting
myself with giving a short account of the progress of the case
from day to day.

On March 18th, the first exercises were begun, no mechan-
ical manipulation, however, being undertaken on that day.
I had requested the presence of the young physicians (externes)
of the division, to act in the first place as assistants, and
secondly, that I might make them familiar with the methods
used.

March 19, second day. The past night was worse, the pains
being more severe. To-day the first mechanical manipula-
tions were begun. It was necessary for the externes to hold
the patient during their execution. The manipulations and
the muscle exercises combined produced considerable exhaus-
tion, so that I begged that the patient might have daily, as a
recompense for the pain endured, a quarter of a litre of wine.

20//i. Pains even more severe; the patient not sleeping at
all. Treatment continued nevertheless.

215^. In spite of continuous pain, slept a little last night.

22flf. Pains diminishing; slept all night; he is now able,
though only with much trouble, to get normally into bed.
Active movements begin to be stronger.

23rf. Complaining of increased pain, especially on the left
side.

24^A The night was easier, the pains being less ; the walk-
ing exercises are quite satisfactorily performed, though the
carriage is still faulty and the motions very timorous. Never-
theless, he can now flex the left thigh at the hip-joint. The
right thigh performs its motions pretty well.

By chance I happened to surprise the patient about an hour
after treatment. He was sitting on a chair in the old faulty
manner ; that is, on the right buttock, the left thigh being
extended at the hip. On being reprimanded he at once
assumed the correct position. I ordered him to go to bed

184

OASES.

and rest his muscles whenever they felt tired, but when
sitting, to sit properly. This should always be the rule.

25M. Bad night. The areas formerly anaesthetic have now
become so hyperaesthetic (probably as the result of the mechan-
ical manipulations) that he cries out when they are touched.
When firndy grasped in the hand, however, or deep pressure
made upon them, the pain becomes less, or gradually disap-
pears, but as soon as the pressure is removed, the pain returns
and the skin becomes as sensitive to touch as before. The
pains in the nates, however, are much less severe than
formerly.

26^/i. Day of rest ; no treatment of any kind.

27^/i. Hyperaesthesia continues. The softest touch of the
hand, even the contact of the shirt, causes pain, so that the
patient cannot bear to wear any clothes. The sensitiveness
on either side of the sacrum^ at the ischial tuberosities, and in
the popliteal spaces has, however, nearly disappeared. Two
points on the nates, each quite symmetrically placed six centi-
metres (2f inches) from the coccyx, and one on the left thigh
about two centimetres (f inch) above the trochanter, are still
very sensitive. The anaesthesia which existed below the pop-
liteal space has disappeared entirely, sensation there now being
normal; micturition still as difficult as ever; general condition
good.

(The three following cuts are introduced here simply to
save the time of referring to an anatomical atlas. For the
physician must always distinctly keep in mind the anatomical
relations of the muscles to the bones, especially their origins
and insertions, as these being very frequently the seat of the
more severe pains, require, in consequence, a more severe form
of treatment.)

Continuation of mechanical manipulations is rendered im-
possible by the extreme cutaneous hyperaesthesia. Micturition
having increased in difficulty (it now takes fifteen minutes
straining before the stream is started), and as Dr. Blatchez, in
view of the bilateral distribution of the sciatica and the
urinary difficulty, thinks it likely that the trouble is of central
origin — which, indeed, seems not improbable — it is agreed to
suspend all treatment till April 1st.

CASES. '

135

In the course of the four following days the patient’s condi-
tion improved in the most astounding manner. The nights of
March 27th, 28th, 29th and 30th, were still, on the whole, very
bad, the pain being intense, but on April 1st he began to sleep
well, the pains diminished, and the functional powers of the

Fig. 35.

muscles increased daily. The hypersesthesia of both thighs dis-
appeared entirely. Micturition, too, became perfectly normal.

On March 30, for the first time, he went up and down stairs
without pain, and was able to walk about in the hospital gar-
den for two hours without fatigue, and in an incredibly short
time he returned to his normal condition, so that on April 4

CASES.

137

— after sixteen days’ treatment — he was entirely cured and
could perform any desired movement with entire ease. All
increased sensibility had disappeared, with the exception of
two points on the nates at the exits of the sciatic nerves, where
there was still a slight hypersesthesia, scarcely worth men-
tioning.

In view of the extraordinarily favorable results obtained,
Prof. Blachez at once ordered another case of sciatica — milder
in degree than the first — to be treated by the young physicians
of his division, whom I had been, meanwhile, instructing. They
had assisted at the first patient’s treatment, and were becoming
quite proficient in the execution, both of mechanical manipu-
lation and passive movements.

The result in the second case was as brilliant as in the first,
and I think I may fairly assume that these successes of mechano-
therap3^ have helped to convert many previous unbelievers in
Paris hospitals. However, in German-speaking countries, too,
the number of unbelievers is still pretty large, and I must
confess to having myself belonged to that number, but seven
years ago. To be really convinced of the eflicacy of this form
of treatment^ it is necessary to have actually witnessed some
of its results. Even Busch himself, however, has his doubts
upon its ultimate success. In his excellent treatise on the
subject^ (in which, it is true, neuralgia is but superficially
touched upon) this eminent surgeon says: “The effects,
however, are but transient, and we cannot hope to obtain
lasting results from either gymnastics or massage, except,
perhaps, in those cases where neuralgias are of hysterical, or
hypochondriacal origin. In this class of cases a vigorous
movement cure may not be without benefit.” If Busch w’ere
to apply these remarks to trigeminal neuralgias alone, I would
be willing to subscribe to them, but where it is a question of
neuralgia having its seat within the larger muscles, I feel
bound, in view^ of all my previous experience, to most decidedly
differ from him, and there is nothing I more desire than the
opportunity to prove my assertions by the citation of cases.

It may strike the reader as very remarkable, that the

' General OrthopafMlics, Gymnastics and Massage, in Ziemsseu’s Handbook of General Therapeutic^
German Bd., Leipzig, 1882. Vol. V. Am, Ed., Wm. Wood & Co., New York.

138

MECHANO-THERAPY IN RECENT CASES.

case just described, which on account of long duration,
great extent, and marked degree of functional derangement,
was certainly to be counted among the severest forms of the
malady, was cured in such a surprisingly short space of time.
The cause of this is most likely to be found in the very ener-
getic measures which I thought myself justified in using
toward the patient, who was a strong, healthy young man, be-
longing to the laboring class. Had the patient been a delicate
and sensitive young lady, surrounded by an anxious family, it
would have been impossible either to begin the manipulations
with as much force, or to have gone from one to the other so
quickly, nor could the passive movements have been performed
with as much vigor as they were. By treating the patient as
I did, I certainly shortened the time of his suffering, and a
letter overflowing wfith protestations of gratitude since received
from him, gives me the quieting assurance that the energetic
nature of my procedures redounded only to his benefit.

ON THE SUITABILITY OF MECHANO-THERAPY FOR
RECENT CASES.

We all know how sciatica will disappear, often after only a
few days’ existence, perhaps, without any treatment whatever
having been employed. This is especially true of those cases
resulting from exposure, which generally yield either to the
application of heat, or a vapor bath, or to cold water and
friction. Several days, however, will always be requisite for
a cure.

Where mechanical treatment is used in these cases, a cure
is likewise obtained, only with the difference that the patient
is able to use the limb again within twelve to twenty-four
hours. Of course, not every patient will submit to the pain
necessarily incurred during the treatment.

Lumbago, stift* neck, in fact, all forms of recent muscular
rheumatism, may be treated in this way, but instead of describ-
ing each one in particular, let me give a case in point recently
coming under my observation.

MECHANO-THEBAPY IN RECENT CASES.

139

Case III. — Mrs. M. H., aged twenty-nine. Frequent sufferer
from supraorbital neuralgia. Of spare habit, and poor mus-
cular development, but otherwise healthy. In August, 1882,
I was called to see her, and found her suffering from pain so
severe as to prevent her even turning in bed. She distinctly
remembered having gone down into the cellar two day before,
while in a perspiration. She was exceedingly desirous of being
cured immediately, it being the time of year when she had the
most work to do.

Examination showed both sciatic nerves to be affected. The
muscles of the hips, buttocks, and posterior part of the thighs
were not only rendered useless, but were extremely sensitive.
A few painful points were found. The patient was unable to
turn in bed, and lay moaning and complaining — as helpless as
a block of wood. I proceeded to explain to her that there
was, indeed, a very rapid cure for her malady, but that it was
not of the kind that could be bought at an apothecary’s; that,
ill fact, I carried it always about with me (and here I showed
her my two hands) ; and that, although its application caused,
no doubt, a good deal of pain, yet that the pain lasted but for
a short tinier only. But I also told her that I could, on the
other hand, guarantee that most likely on the very next day
she would be able to be at her work at her wash-tub again.
She answered she was ready to try anything, if it would only
enable her to work.

I then began that series of mechanical manipulations so
frequently described; beginning with stroking, in order to
accustom her to the pain, and then proceeding to first light
then hard pressing. After these came kneading, pinching,
and finally hacking of all painful parts. It is, perhaps, need-
less to add that the pain thus caused was very intense.

Next, vigorous passive movements were tried, especially
forced flexion of the thigh. The legs being bent, I brought my
whole weight to bear upon the thigh, until the knees touched
the body. This exercise is nothing more than a form of nerve-
stretching, similar to that usually done under the influence of
an anaesthetic. I repeated it ten times, and the sensibility of
the nerves having now been deadened, I ordered the patient
to turn over in bed ten times in each direction. She succeeded

140

MECHANO-THERAPY IN RECENT CASES.

in this, though, of course, at the expense of great suffering,
and not without a little help from me. Then, taking the
patient by both hands, I ordered her to rise; at the same
time I stepped backward, and drew her forward, though
she groaned with pain all the while. While in the upright
position, I again began hacking the nates and backs of the
thighs. Wherever it is desired to quickly restore a patient to
the normal condition, hacking must be most vigorously prose-
cuted. Considerable amount of heat should be evolved in the
muscles manipulated, for it is heat which in all probability
brings about the desired molecular changes in the muscles and
nerves.

After a quarter of an hour of continuous manipulation, the
patient had become far less sensitive, so I ordered her to dress
herself and ascend a neighboring hill, about five hundred feet
in height, and up which a good path led. This she did, assisted
by her husband, returning in about an hour. In the course
of the day I repeated the pinching, hacking, etc., three times;
also caused her to go through various motions, including seat-
ing exercises, for an hour each time.

When evening came nearly all the neuralgic pain had left
her, and she was able to execute all movements with ease.
The following day she was able to go to work, which she did
with great rejoicing. After a few days all traces of former
sensitiveness had left.

The possibility of curing lumbago and stiff neck in ten to
fifteen minutes is well known, and according to my experience
all recent neuralgias are equally curable. If the patient
will only patiently submit to the treatment, the physician can
conquer the disease. But — I repeat it again — treatment must
be of the most vigorous kind. The physician who proceeds
timidly, allowing the patient^s cries and efforts to resist, to
disturb him, cannot possibly employ the needed force, and
in the end will only have tortured his patient and accom-
plished nothing. It should be our object to affect the mus-
cles in their very deepest parts (always carefully regarding the
bones), to stretch and concuss the nerves, and to cause an

CERVICO-BBACHIAL NEURALGIA.

141

evolution of heat and to stimulate the circulation within the
tissues involved.

I have cured recent neuralgias in this way so often that I
do not hesitate to assert that not only can the physician always
get these troubles under his control if he desires, but that
there is no other means which acts so promptly and certainly.
Thousands of unhappy sciatica patients have been condemned
to years of unbearable pain, and even atrophy of their muscles,
simply because in the beginning they had not been treated on
mechanical principles.

I know of but one objection that could be raised against
this form of treatment. It might be said that perhaps these
recent sciaticas would have yielded equally well to a raustard-
. plaster, or to a vapor-bath, or even to a few days’ rest in bed.
Of course this, as well as the opposite possibility, must be
admitted; nevertheless, under the circumstances mechanical
treatment can at least do no harm, while there is always the
probability of its preventing the malady from getting a firm
foothold in the system.

I had the misfortune myself to suffer for two years from an
attack of sciatica, which resisted all ordinary forms of treat-
ment. Finally on doing nothing, it disappeared of its own
accord. Had mechano-therapy enjoyed at that time (1873)
the reputation which it does to-day, and had I been so familiar
with its powers as I now am, I need not have suffered, through
two long years, the pain I did.

CERVICO-BRACHIAL NEURALGIA.

Cervico-brachial neuralgias, corresponding to the distribu-
tion of the four cervical nerves and a part of the first dorsal,
affect the shoulder, pectorals, the arm and forearm, and the
region over the spinous processes of the four lower cervical
and two upper dorsal vertebrae. The painful points are
numerous, and are distributed as follows : In the axilla, at
the lower angle of the scapula, on the back of the shoulder,
in the flexure of the elbow, and at the points of exit of the
branches of the musculo-cutaneous nerve, and of the ulnar

142

CERVIOO-BRACHIAL NEURALGIA.

nerve above the internal condyle; at the wrist-joint, and along
the radial nerve. Marked exacerbations of pain sufficiently
severe to rob the patient of sleep, are common at night.

Diagnosis is not always easy. In the first place, in the region
involved, the areas of nerve distribution are hard to define ;
and secondly, it is a favorite seat of muscular rheumatism.
However, even in the case of its being rheumatism only, we
may all the more readily count upon the success of mechan-
ical treatment, for myalgia is even more amenable than
neuralgia.

Should there be any question of rheumatic arthritis, or of
bone disease, the differential diagnosis must be made with the
greatest care, for a mistake, and the consequent employ-
ment of mechanical means, might be followed by the gravest
results.

Though Erb prescribes absolute rest for the treatment of
cervico-brachial neuralgia, I feel justified, in view of an ex-
tended experience, to recommend mechanical treatment for
these cases as confidently as I already have for sciatica. In-
deed, if we proceed upon the basis that neuralgia in general
is to be cured by stretching the affected nerve, there is no
reason why this variety of it should not, a priori^ be as well
adapted to mechanical means as any other.

While treatment must be applied to all the muscles affected,
it frequently happens that certain ones, having become paretic
or even entirely paralyzed, need special attention. Areas of
anaesthesia and hyperaesthesia are common, and vaso-motor
and trophic disturbances may also occur. These symptoms
as well as the fundamental trouble all disappear together as
treatment progresses. Regarding the form of treatment, it
must, of course, always be carefully chosen as adapted to the
site of the pain and to the nature of the motor disturbances.
In some cases the muscles chiefly involved are those which
arise from the occiput and the spinous processes of the
cervical, dorsal, and lumbar vertebrae, and are inserted into
the scapula — namely, the trapezius, the latissimus dorsi, the
rhomboideus major and minor, and the levator scapulae — in
other words, the rotators, adductors and elevators of the
scapula and the retractors of the arm. In other cases it will

CERVICO'BRAOHIAL NEURALGIA.

143

be the muscles connecting the scapula with the humerus, — the
deltoid, supraspinatus, infraspinatus, teres minor and major,
subscapularis and coraco-brachialis, these being the elevators,
external and internal rotators of the arm. Again, it will
be found that the muscles connecting the shoulder with
the forearm are most aftected, as the biceps, brachialis anticus.

Fig. 38.

and triceps — L r., the flexors, extensors, and external and in-
ternal rotators.

In a few cases all these various groups will be found to be
about equally affected.

Let us assume we have to treat such a case, the neuralgia
being on the left side.

After first performing the required movements upon the
patient, he is ordered to imitate them himself, and while doing
80, we test the aftected muscles with regard to the degree of their

144

CERVIOO-BKAOHIAL NEURALGIA.

loss of function, and the general sensibility of the parts in-
volved. As in sciatica, treatment is begun with active and
passive motions, mechanical manipulations following.

First Day of Treatment . — Passive shoulder-lifting, performed
as follows: The physician standing in front of the patient,
grasps with his right hand the patient’s elbow, — the forearm
being flexed at a right angle — and while counter-pressure is
made with the left hand upon the shoulder, the arm is
suddenly pushed vertically upward; after this has been re-
peated ten times, the patient is ordered to perform the motion
actively, as shown by the dotted lines in Fig. 39.

The movements, which will be made simul-
taneously by the sound shoulder, are only ad-
vantageous inasmuch as they serve as a means
of comparison by which to judge the disability
of the opposite side.

The adductors of the scapula (the rhom-
boideus major and minor) must be passively
and actively exercised, while the patient is en-
gaged in the above. This is performed by the
physician, standing behind and pressing both
scapulae as far as possible, inward toward
the spinal column. The more forcibly this is
done the better. The next thing in order is
pressing the affected muscles; this is performed
quite gently in the beginning, with the finger
tips only, and then more energetically, using
the flexed fingers first, and afterward the fist itself. The ex-
aggerated sensibility of the muscles becomes in this way
gradually numbed. The manipulations need not occupy more
than ten to fifteen minutes. Altogether, the treatment of
this form of neuralgia is far less fatiguing, and of much shorter
duration than that of sciatica.

Second Day of Treatment ,— patient may declare himself
even less able to use his arm than before treatment was begun,
and, as in sciatica, the pain will probably be increased during
the first few days. The physician, however, need not be dis-
turbed by this, but should proceed to the execution of rotary
movements of the scapula, and of internal and external rota-

CERVICO-BRACHIAL NEURALGIA.

146

tion and depression of the arm. For the first of these —
scapula rotation — one should stand behind the patient, and
seizing the bent arm, near the elbow, push it forcibly upward
and outward, repeating the exercise ten times. Rotation of
the arm is performed by the physician, standing in front of
the patient, grasping the arm extended at the elbows, in both
hands and rolling it inward and outward.

The next is generally a fatiguing operation for the physi-
cian. It consists in grasping the patient’s shoulders, and
moving the whole extremity — the scapula participating — first
forward and inward, and then backward, and outward. This
exercise extends the antagonizing muscles to their maximum,
and at the same time stretches their contained nerves.

The mechanical manipulations of yesterday are to be re-
peated, with the addition of pinching the muscles. In order
to be able to grasp the trapezius and supraspinatus, the
patient must be directed to lean his head backward and out-
ward toward the affected side. Frequently the outer edge of
the latissiraus dorsi, also the origins of the teres major and
minor, and of the subscapularis, will be found exceedingly
sensitive, and will consequently require especial manipulation.

Third Da^j of Treatment — Repetition of all previous exercises
and manipulations.

As new exercises, we have essays at raising the arm. The
deltoid muscle, while it is the most powerful of all the muscles
of the upper extremitj", is at the same time most difficult to re-
store to functional integrity. While in sciatica we prepare the
patient for walking exercises by making him practise placing
his foot upon the horizontal bar, so the apparatus delineated
here serves a similar purpose in restoring the motion of raising
the arm. It is, besides, useful for a variety of exercises, as we
shall see later. For the present we need only consider the
portion a, which for brevity we will call the ^‘rung-bar.’’
Standing in front of this, the patient raises his arms to the
highest rung he is capable of grasping, and rests them there
for half a minute, repeating the exercise ten times.

Muscle-hacking should be performed to-day for the first time,
care being taken to avoid striking the bones, and to grade the
force used according to the thickness at the muscular layers,

2 3m

146

CERVICO-BKACHIAL NEURALGIA.

using more where they are thick, as over the deltoid, and less
where thin, as in the infraspinous fossa. The scapular spine
is very sensitive, and hacking over it would be as useless as
it might be injurious, for a blow upon it of as much force as
those used upon the trapezius and supraspinatus, lying just
above, might do considerable damage.

Anyone at all familiar with anatomy ought to be perfectly
competent to perform all these manipulations upon the clothed
body (and in women this is absolutely necessary), but the inad-
visability of entrusting the treatment to anyone not a physician
will be at once apparent. Not that I wish to say that it would
be absolutely impossible to a layman, but he should have been
previously instructed by a physician in the anatomical relation-
ship of the parts.

CERVICO-BRACHIAL NEURALGIA. 147

Superficial hacking is just as useless as superficial pinching,
for both afl[ect only the skin. Those manipulations, on the
other hand, which penetrate the deep-lying parts, undoubtedly
aflfect the terminal nerve twigs themselves, whose neurilemma,
according to Kiihne,^ becomes continuous with the sarcolemma,
the rest of the nerve fibre losing itself within the muscle fibre.

Heat must necessarily also be evolved by these manipula-
tions, and this heat not only endows the molecules of which
the muscles are composed with energy; but accomplishes also
what may be called internal work — i, r., that work which is
performed within the heated muscle itself, and which results
in a rearrangement of its molecules.

The muscles to be hacked must, of course, be in a state of
relaxation. To this end the physician must put the arm, fore-
arm, and shoulder in positions in which the muscles to be
manipulated are neither in a state of contraction, nor, from
the action of their antagonizers, in one of forced extension.
This is best accomplished by selecting the mean between ex-
treme flexion and extension. In hacking the muscles of the
forearm — pronators and flexors as well as supinators and ex-
tensors — it is advisable to support the forearm in one’s left
hand, for if laid upon some firmer basis the internal condyle is
apt to be hurt each time the arm is struck. When the elevators
and external rotators of the arm (deltoid, supra- and infra-
spinatus) are to be hacked, the extremity should be allowed to
hang loosely from the shoulder. In hacking the adductors,
retractors, and attractors of the shoulder (teres major, latissi-
mus dorsi, and coraco-brachialis) the extremity should be
slightly adducted, while the forearm, flexed at the elbow, is
supported in the left hand. Though it is impossible to hack
the subscapularis on account of its position, yet as the origins
of those fibres which arise along the outer and inner border
of the scapula are frequently the seat of intense pain, they
should be thoroughly pressed and punched with the finger-tips.
When the scapula is raised as far as is possible from the trunk
there will be no difficulty in getting the fingers in along its
inner edge to the distance of one centimetre or more, and in

1 Hermann, Lohrbuch der Phyaiologie.

148

CERVICO-BBACHIAL NEURALGIA.

this way, by poking, the same effects are gained as by hacking.
In hacking the trapezius and supraspinatus, the spine of the
scapula is best avoided by beginning the manipulation at the
point furthest removed from the affected shoulder, and keeping
the blows always parallel to the spine.

It is immaterial whether the patient stands or sits during
the treatment.

Fourth Day of 'Dealment. — Arm-raising is to be continued
until the patient is able to reach the highest rung his own
height will allow.

The new passive exercise consists in arm-circling; performed
by the physician seizing the affected arm and swinging it round
and round so as to describe the largest possible circle, first ten
times to the right, then an equal number of times to the left.
Repetition of all previous manipulations.

Fifth Day of Treatment — Each day should be begun with
the repetition of all previous exercises, just as in the treatment
of sciatica, and the addition of a single new
passive and active movement daily is quite
sufficient.

New exercise : Arm-raising sideways first
ten times passively, then ten times actively
— the active movement to be done with the
aid of the rungs, the patient standing side-
ways to these and beginning at first with a
low one, and gradually going higher and
higher.

Sixth Day of Treatment — Drawing the arms
downward and backward (involving the in-
fraspinatus, teres minor, and latissimus dorsi).
When these movements are performed pas-
sively the arms should hang by the side, the
elbows being bent, when, in thin persons it
may be possible to draw them so far back as
to make the elbows touch, but in corpulent or very muscular
individuals this will not be possible. This movement puts the
two pectorals and the teres major violently upon the stretch
and causes considerable pain if they be sensitive, but it is this

CEBVICO-BRACHIAL NEURALCxIA. 149

very pulling and stretching which, in a few days, deadens
sensibility.

Seventh’ Day of Treatment . — Practically the same exercise as

Fig. 4 * 2 .

150

CERVICO-BRACHIAL NEURALGIA.

the above, only attained by causing the patient to hold a stick
thrust through both elbows, behind his back, for two or three
minutes at a time. Sticks of larger diameter should be used
each day.

Eighth Day of Treatment — Intensification of this exercise:
by causing the patient to grasp a rung behind him standing
with his back toward the rung-bar. This is the more difliicult
on account of the affected muscles being forced into activity
in order to seize the rung.

Ninth Day of Treaiment , — Clasping hands behind the back
(Pig. 43), both actively and passively.

In men the same results may be obtained by ordering them
to take an object from their coat-tail pockets and then to
replace it. This act, though apparently simple, proves some-
times BO diflicult as to require several days to acquire.

Fi«. 40

Pig. 44.

Tenth Day of Treatment . — ^By this time the affected muscles
will have been so strengthened as to admit of vigorous
movements of extension being indulged in. These may be
performed in five different directions (Pigs. 44 to 46); upward,

CERVICO- BRACHIAL NEURALGIA.

151

downward, forward, backward, and outward, and when mus-
cular power has still further increased dumb-bells may be
used. These exercises may possibly occupy the time until the
fifteenth day of treatment, without the addition of any new

Fig. 45.

Fig. 40.

form of movement, with the exception of adding dumb-bells to
the former motions of arm-raising and arm-circling.

Fifteenth Day of Treatment — The patient has now arrived at
the period when he may be expected not only to perform, un-
aided, the most diflicult of the active exercises required, but
to allow also of the more vigorous passive ones being executed
upon him.

For the passive exercise the following apparatus is used.
The bar c is stationery ; h being attached to the upright /,
which admits of lateral motion by a tongue at either end,
sliding in corresponding grooves of the horizontal cross-pieces
d and e.

The patient, standing on the lower cross-piece, grasps the
bars c and b in either hand, while the physician draws the up-
right/ as far as possible from c, thus extending the patient^s
arms to their utmost. The upright f is then fixed by means
of pins dropped into holes in the cross-pieces (not shown in

152

CERVICO-BEACHIAL NEURALGIA.

the cut).^ Extension is not to be performed gradually, but
with a sudden jerk, and should be repeated ten times.

Fig. 47. b a

The following half-active, half-passive exercise may be
undertaken on the rung-bar a, by the patient standing with
his back close to it, and grasping a convenient rung over his
head. The physician then seizes him by the body just beneath
the arms, pulling the trunk forward, while the feet are kept
close to the lower end of the bar (Fig. 42). This exercise
affects the muscles in a variety of ways. Both pectorals, the
deltoid (in part), the biceps, and coraco-brachialis are put to
their maximum degree of tension, yet are at the same time
forced to actively steady the trunk. The subscapularis, teres
major, and latissimus dorsi are likewise stretched, together
with all the nerve trunks lying in the axilla.

1 A simpler form of apparatus may l)e constructed with ropes, pulleys, and weights, the latter
being graded according to the violence it is desired to use. — Trans.

GENERAL CONSIDERATIONS.

153

In this combination form of exercise we see that a typical
nerve-stretching operation has been performed, — one which
kinesiatricians have been in the habit of practising for years,
long before nerve-stretching under ansesthesia was even
hinted at.

Fig. 19, taken from the Oong-Fou^ illustrates a similar form
of passive muscular extension, whose action, however, is less
intense.

Similar physiological effects are obtained by the old peasant
women in Hungary, with their Csomor,

Sixteenth Day of TVeatmerit, — When, in the physician’s judg-
ment, the muscles of the shoulder have attained sufficient
power, climbing exercises on the rungs may be begun, at first,
under constant superintendence to guard against accidents by
falling. This exercise should be done first with the patient
facing the rungs — as in ordinarily ascending a ladder — and later
with his back toward them, this being the more difficult form
of the two.

Seventeenth^ eighteenth^ nineteenth^ and twentieth days of treatment
are to be devoted to practising all the previous exercises.

Twenty-first dc^y of treatment is to be one of entire rest.

Tiventy-second Day of Treatment — Hanging from the rungs
by the hands, and climbing from one to the other by them
alone, may now be tried, and the ability to perform this, the
most severe of all the tests to which the shoulder muscles
can be put, is a proof of the patient’s entire cure.

General Considerations.

The remarks made upon prognosis, and upon duration of
treatment, in considering sciatica are equally applicable here.
And I would again say that the plan I have just detailed is but
a general one, which may have to be extensively modified to
meet various cases. In general, however, it will usually be
found best to begin with the simpler and easier exercises, and
then proceed to the more complicated and difficult ones.

Cases which have existed for years require a skilled and
practised hand, while recent ones, even though the distribution
of the neuralgia be quite extensive, may, simply by the aid of

164

CERVICO-BRACHIAL NEURALGIA.

energetic passive and active exercise, and without any appar-
atus whatever, be cured in the incredible short space of twelve
to twenty-four hours.

It sometimes happens that we see cases where, in consequence
of exposure to cold, there is a combination of bilateral cervico-
brachialgia with bilateral sciatica. The painful points are pres-
ent and the pains follow the course of the nerve trunks, while
at the same time large muscle groups may be exceedingly ten-
der, and sulFer interference of function. The question will
naturally arise. Are these cases of neuralgia or of muscular
rheumatism, or are they combinations of both ? It would not,
however, be justifiable to wait for the appearance of typical
paroxysms of neuralgia, in order to determine the differential
diagnosis, because in mechano-therapy we possess a means of
entirely curing the patient within twelve to thirty-six hours.

Case IV. — L. H., aged fifty-six, telegraphist in Arco, con-
sulted me in October, 1878, for right cervico-brachial neural-
gia of three years’ standing. He knew of no reason for the
trouble, and I was hardly inclined to look upon his occupation
as a cause, although it was the arm and shoulder used in
working the key of his instrument which were affected.
During the past year he had employed all sorts of remedies,
including electricity, but without effect.

On examining him an extensive eruption, covering the neck,
chest, and arm, produced by a vesicating ointment prescribed
for the relief of his trouble, gave evidence of the last form of
treatment used. It had irritated the skin almost to the point of
inflammation, but without in the slightest degree relieving the
pain.

Four weeks of mechanical treatment, occupying daily not
more than ten to fifteen minutes, cured him completely. I
have seen him repeatedly since, and he has had no return of his
old trouble. Whenever he feels the slightest pain in his arm
or shoulder, he goes through the appropriate exercises laid
down for him, and is very happy to be able to cure himself
by this simple means and so to keep at work.

When treatment was first begun he was extremely sensitive,
and moaned and groaned with every form of movement used
— active, passive, or mechanical. This condition continued

TBEATMENT OF CER VICO-OCCIPITAL NEURALGIA. 166

until near the end of his cure. Nevertheless, in spite of it,
he all along thankfully acknowledged his satisfaction at the
improvement which was visible from day to day. I mention
this fact, to show the physician that he must never be deterred
by any expressions of pain the patient may indulge in.

TREATMENT OF CERVICO-OCCIPITAL NEURALGIA.

I have never had the opportunity to observe an uncom-
plicated case of this trouble, but I have often seen it associated

Fig. 48 .

with neurasthenia and cephalalgia. The great occipital nerve
is the one most frequently involved. The pains radiate toward

166 MECHANICAL TREATMENT OF NEURALGIAS.

the vertex and forehead and are often combined with trigem-
inal neuralgia. Mechanical manipulation — pressing, knead-
ing, pinching, and mild hacking — of the muscles affected
(trapezius, sterno-cleido-raastoid, splenius capitis et colli),
proved in all cases efficacious, generally effecting a cure of the
occipital neuralgia in from two to four weeks, while the ver-
tical and frontal persisted. Active motion of the head in all
directions, including rotation, is a useful auxiliary to the purely
mechanical treatment.

Case V. — Mr. E. K. suffered from severe cephalic neuras-
thenia with occipital and frontal neuralgia, the result of
mental overexertion caused by deciphering almost illegible
manuscripts till far into the night. The pains had finally
become so severe that for months he had been unable either
to read or write. Worst of all, were certain pains at the
back of the eyeballs, frequently accompanied by the sensation
of seeing sparks and lights.

He had gone through a course of hydro-therapy under
Winternitz, and had also employed mechanical treatment.
Nevertheless, I resolved to try the latter again.

In three weeks the occipital neuralgia disappeared com-
pletely. The trigeminal neuralgia, however, and the pain in
the vertex, brows, and eyes continued as before, temporary
relief, lasting from fifteen minutes to three hours, only being
afforded. This temporary alleviation followed so invariablj’,
that whenever the pains returned with more severity than
usual, the patient would go in search of me in order that I
might operate upon him. Unfortunately, the relief lasted no
longer than a few hours. On leaving my institution at Aussee,
his occipital neuralgia was cured, but his other troubles con-
tinued, even after subsequently visiting two water-cure estab-
lishments.

MECHANICAL TREATMENT OF TRIGEMINAL AND INTER-
COSTAL NEURALGIAS, AND OF CEPHALALGIA.

While we can always count with certainty upon being able
to favorably influence all neuralgias of nerves seated within
or between muscles, we find that when we turn to the mechan-

MECHANICAL TBEATMENT OF NEURALGIAS. 167

ical treatment of neuralgias of nerves situated between the
skin and an underlying bone, our power becomes as limited as
it was before almost boundless.

Many of these cases are marked by the peculiarity that
alleviation, or even the entire disappearance of the pain,
follows manipulation ; unfortunately, however, this disappear-
ance lasts for a short time only. In others the gentlest mani-
pulations prove unbearable to the patient, and it seems sense-
less to persist in so painful a form of treatment when success
is more than doubtful ? Trigeminal neuralgia, in particular,
evinces a most stubborn resistance to mechanical treatment.
Of course, such cases as arise from exposure to cold, from
carious teeth, or from anaemia, etc., yield to other forms of
treatment, or disappear when the cause is removed.

There are two principal reasons why trigeminal neuralgias
prove so often unamenable to treatment of any kind, whether
mechanical or medicinal.

First. Because a certain class of these cases are traceable
either to inherited disposition or dyscrasia, or, in some cases, to
organic tissue changes, often of central origin. The diagnosis
in these cases ^s surrounded with difficulties, and it is almost
as impossible to recognize the existing anatomical causative
changes during life, as it is to influence them by any form of
treatment that may be adopted. Autopsies and resections of
nerves have shown the existence of the most various lesions,
among which may be mentioned thickening of the neurilemma,
sclerosis and degeneration of the Gasserian ganglion and the
branches connected with it, flattening and atrophy of the
ganglion and its branches, calcareous concretions in the peri-
neurium, etc.

Second. We have already seen, in discussing sciatic and
cervico-brachial neuralgias, how necessary it is for the cure of
long-standing cases, that the mechanical interferences used
should be of the most energetic kind. The tissues to which
the nerves are distributed must be influenced, even to their
very remotest parts, by all the different forms of manipulation
at our command. It would seem as though the nerve were
forced to participate in the benefits accruing from the increased
circulation occurring in the muscle, in whose fibrillss its own

168 MECHANICAL TREATMENT OF NEURALGIAS.

ultimate fibres become merged — in other words, that the
restoration of the nerve is secondary to that of the muscle.
The condition most favorable for the application of mechano-
therapy, therefore, is absent in these cases, where, instead of
substantial groups of muscles, we find only skin, or muscles
spread out in thin layers, to operate upon. Then, too, assum-
ing concussion and its consequent molecular changes to be
potent factors influencing the cure, we have in the case of
the trigeminus insuperable difficulties in the way of applying
the necessary hacking, kneading, and pinching to the affected
nerve. Stroking and pressing the nerve against its bony
support, are the only manipulations possible, hacking — the
most powerful means for producing concussion — being totally
inapplicable to the head and face, while those portions of the
nerve lying within bony canals are entirely withdrawn from
the influence of the physician’s hand.

In Case V., already reported, we have a most striking
proof that it is in the muscles that the true field of mechano-
therapy lies. In this case one and the same cause (mental
over-exertion and visual strain from continuous reading)
developed cerebral neurasthenia, and occipital and trige-
minal neuralgia, the latter of the first and second divisions,
producing simultaneously ocular, supraorbital, and supra-
maxillary pain. The occipital neuralgia soon yielded to
mechanical treatment, for all the muscles attached to the
superior curved line (splenius capitis et colli, biventer cervicis,
and complexus) as well as to the inferior curved line (rectus
capitis posticus major and minor, and obliquus capitis superior)
could be influenced by kneading and hacking, even down to
their very remotest portions, while the frontal nerve from its
lying under the orbital roof, was entirely inaccessible to treat-
ment.

The supraorbital nerve, emerging from the supraorbital
notch and spreading over the forehead as far back as the vertex,
only admits of stroking, for the skin lies so close to the bones
that it is impossible to seize the nerve between the fingers.
The same conditions obtain for the second division of the
trigeminus, with its temporal and infraorbital branches.

Care must be exercised in manipulating the parts of the

MECHANICAL TREATMENT OP NEURALGIAS. 159

skull covered only by skin. The manipulations should be
limited to a slow, uniform, stroking pressure, continued in
certain directions and executed with the tips of the first,
second, and third fingers, or with the thumb. Rotatory, vibra-

Fig. 49.

tory movements are also applicable, especially over particularly
sensitive parts, as at the point of exit of the supraorbital
nerve.

On the hairy scalp a mild form of beating, performed by
drumming with the tips of the fingers, is often of use.

The direction in which the manipulations are pursued is
for many patients quite immaterial, while others feel more
comfortable if the motions are executed from above downward,
stroking in the opposite direction causing discomfort, or even
distinctly increasing the pain. Many patients are so greatly
relieved by a daily course of rubbing and stroking that one is
often misled into the belief of having effected a permanent
cure. In others again, the relief does not last longer than

160 TREATMENT OF INTERCOSTAL NEURALGIA.

perhaps a few hours, while there are still others who are posi-
tively made worse by any form of mechanical treatment
whatever.

MECHANICAL TREATMENT OF INTERCOSTAL NEURALGIA.

Intercostal neuralgia is better adapted to mechano-therapy
than the forms just discussed, the nerves involved being more
accessible to the physician’s hand.

The intercostal nerves lie in the intercostal spaces, below
the intercostal arteries and between the internal and external
intercostal muscles. About the middle of their course they
send off* branches which pierce the external intercostal muscle.
These branches (the lateral cutaneous) supply the skin of the
chest and abdomen, and thus afford favorable opportunity for
the application of mechanical treatment.^

Pressing and kneading the painful areas will, in most cases,
suffice. The six upper nerves, whose lateral branches are
underlaid by the ribs and the thick pectoral muscles, allow of
more vigorous hacking than the six lower ones, which dis-
tribute themselves partly to the rectus abdominis and partly to
the latissinius dorsi.

It seems hardly necessary to caution against mistaking inter-
costal neuralgia for those diseases of the pleura, lungs, or
heart, which may simulate it. A careful examination of the
thoracic organs should always determine the diagnosis. Mis-
taking it for muscular rheumatism, on the other hand, will
be followed by no harm whatever; for, as we have seen, there
is no better treatment for both the acute and chronic forms of
this trouble than the mechanical.

Case VI. — Dr. G., of Aussee, suffered for several weeks
from an annoying pain in the left hypochondrium, increased
by motion and respiration. There being a slight rise of tem-
perature every evening, and the region between the kidney
and rib becoming somewhat tense, giving to the* finger the
impression of a solid body lying beneath, it at first occurred
to me that my colleague might be suffering either from an

^ Probably nothing is so rapidly efflcacions in the treatment of intercostal or lumbar neuralgias
as the application of the Paquelin cautery.— Tuans.

TREATMENT OF CEPHALALGIA.

161

exudation into the pleura, or perhaps even from some new
growth in this region. As this trouble rendered the pursuit
of his vocation more and more laborious, his wife, who was
much concerned about him, asked me to see him.

His case was, in truth, somewhat obscure and puzzling.
Pleurisy I was able to exclude. Careful examination revealed
a very painful spot between the sixth and seventh ribs on the
axillary line — mere pressure with the finger causing him to
cry aloud — the pains radiating toward the hypochondrium.
Each inspiration was accomplished by a sticking sensation in
the side.

As physical examination definitely excluded any pulmonary
or pleural disease, I felt justified, in view of similar observa-
tions, in making a diagnosis of intercostal neuralgia.

I began treatment at once. I had him lie on his side and
then manipulated the painful area by pressing, kneading, and
hacking it. This caused so much pain that it was only with
great difficulty that I was able to complete my labors, for my
colleague made a most lively resistance. When, however, I
had finished, he found he had been much relieved, for the
sticking pain on deep respiration had almost entirely gone.

The next day I repeated the treatment, which sufficed to
cure him completely. The sensitiveness disappeared and
along with it the fever. Since then he has had no return of
the trouble.

MECHANICAL TREATMENT OF CEPHALALGIA.

It becomes necessary, in view of the manifold causes of
habitual headache (which often lasts with occasional interrup-
tion for years) to accurately formulate those conditions of its
existence under which we may expect some reasonable amount
of success from the application of mechanical treatment.

Of course, no physician would think of using this treatment
where headache was the result of fever, of indigestion, of
cerebral tumor, or of periostitis of the cranial bones. ITeither
could we ever look for success where there was a question of
syphilis, of disease of the cerebral substance, of chronic plum-
bism, or of alcoholism.

162

TEEATMENT OF CEPHALALGIA.

On the other hand, when headache is the result of ansemia,
hysteria, or neurasthenia, mechano-therapy is of the greatest
service. And the same is true when it arises from sexual ex-
cesses and onanism, or accompanies hemorrhoids, uterine and
ovarian disease, or chronic gastritis. In this class of cases
gymnastics often efiect a cure when all other means have
failed. But of all varieties of cephalalgia, that arising from
‘‘ catching cold is most amenable to treatment.

For the headache of hysteria, onanism, and neurasthenia,
treatment must not be merely local, but the whole body should
be subjected to massage in the form of stroking, kneading,
and gentle hacking. Passive and active exercise of all the
great muscle groups must be undertaken as well, in order to
obtain the beneficial results which were fully explained in the
chapter on the physiological effects of health gymnastics.

Constant occupation has a most salutary effect on this class
of patients, and the combination of a cold water cure with the
movement cure serves materially to hasten the end in view.
It is diflBicult, however, to accomplish much as long as the
patients remain within the influence of the family circle.
They need the constant supervision of a physician who will
lift them out of the old ruts in which their minds have been
travelling, and change their whole spirit and mode of life.
There can be nothing better for these individuals than the life
in a hygienic establishment. The bustle of the place and
the stimulus of being thrown together with a number of
strangers, together with the regular mode of living, and the
discipline to which they are forced to submit, all combine to
form a strong curative element. In addition to the regular
gymnastics, driving, riding, swimming, rowing, swinging, etc.,
may all be employed to advantage.

For ansemia, a systematic course of active exercises, as it
furthers oxidation, increases the quantity of the blood, stimu-
lates the appetite, promotes assimilation, and increases the
arterial pressure and the power of the heart, will prove most
efficient. With the return of the blood to its normal compo-
sition the headaches will disappear of themselves. These re-
marks hold good — with somewhat less force — for chronic

TREATMENT OP CEPHALALGIA.

168

gastric catarrhs as well. Here, too, the cold water cure is a
useful adjuvant.

For headaches the result of exposure to cold [“rheumatic”
of the Germans], pressing and stroking are most applicable,
which if maintained always lead to cure.

"With regard to the forms of passive and active exercises to
be used, all that 1 have said in my remarks on neurasthenia
applies here.

There still remains to be considered, hemicrania (megrim,
or “ sick headache ”).

Here, too, stroking has been recommended, but I am sorry
to say that my experience with this trouble does not encourage
me to persist in treating it by mechanical means, for I have
never seen any good result from stroking, and this is the only
form of manipulation possible.

Boudet' reports having cured a case of megrim in its incep-
tion by means of an electric tuning fork tuned to a (making
217.6 double vibrations to the second). By means of a short
rod having a knob one centimetre in diameter at one end, the
vibrations were transmitted to any desired point on the skin.

By applying this knob to sensitive portions — as the supra-
orbital region — in healthy persons Boudet was able to produce
local analgesia, and occasionally anaesthesia, in eight to twenty
minutes. This change of sensation was frequently accom-
panied by a feeling of dizziness, and followed by a desire to
sleep. To R. Vigouroux belongs the credit, however, of being
the first to employ the tuning fork in this line of treatment.
He mounted the fork upon a sounding-board, and set it in
vibration with a fiddle bow. In his experiments he found
that in hysterical cases the vibrations produced contractions
[it is not stated of what], and banished the existing anaes-
thesia,— just as the application of various metals, or of a
magnet, or of statical electricity do. He states that he was
able to arrest a tabetic crisis in a woman, by placing her feet
within the box used as a sounding-board.

1 The treatment of pain by mechanical vibration. ProgrSs M6dical, 1881, No. 6.

164 . TREATMENT OF MUSCULAR RHEUMATISM.

MECHANICAL TREATMENT OP MUSCULAR RHEUMATISM.

It is evident, when we investigate the actual nature of
the mechanical treatment of the various forms of neuralgia
just described, that it consists of nothing more than the
thorough manipulation and working of the soft tissues,
especially the muscles, in which the affected nerves ramify,
so that we may almost lay it down as an axiom : the less
soft tissue, the smaller the success.

Accordingly we find that mechano-therapy nowhere meets
with more success than in the treatment of muscular rheu-
matism. Busch^ says: “I have lately had my attention called
particularly to the fact that the pain of rheumatic myalgia is
often cured sooner by massage and movement than by rest
and local applications.” My own experience would lead me
to expunge the word “often,” and substitute for it “always,”
for I feel free to maintain that rest actually prolongs the dura-
tion of the trouble.

Mechanical treatment, too, is frequently a valuable means
for establishing a diflFerential diagnosis, especially in acute
cases. Let us assume that in the case of a painful affection of
the muscles of a certain region, accompanied by disturbance
of their function, we are in doubt regarding the exact nature
of the trouble. Mechanical manipulation and passive and
active movement are now instituted in spite of the patient’s
protestations of pain — provided always, of course, no evident
contraindications exist. If after a second or third repetition,
at intervals of three to six hours, the pains have either disap-
peared or diminished considerably, and the ability to perform
motion greatly increased, we are justified in concluding that
the trouble was muscular; but should there, on the other hand,
be no change in the amount of pain and disability, even after
treatment has been continued for twenty-four to thirty-six
hours, it behooves us to seek for some other source of trouble.

Any physician who has busied himself at all with mechan-
ical therapeutics must have seen dozens of cases abundantly

^ General Orthopaedics, Gymnastics and Massage, Ziemssen's Handbuch der Allegemeinen Therapie,

▼ol. ii., Germ. Ed. Leipzig, 1882. Vol. V., Am. Ed. Wm. Wood & Co., New York.

TREATMENT OF MUSCULAR RHEUMATISM. * 165

proving the assertion made by Martin in the Sociiti de
cine of Lyons as far back as 1837 (and since confirmed by
Bonnet), that recent myalgias, no matter how severe or exten-
sive, whether called lumbago, ‘‘ stifi*-neck,’’ or what not, are
capable of being cured by a single, application of massage.

A case of Stromeyer^s, given in Bosch’s work already
cited, is worth repeating here. A country doctor who was
accustomed to visit his patients on horseback, was attacked,
after having been for some time in a draughty barn, with the
most intense muscular pain in all parts of his body. An old
peasant advised him to mount his horse again, as movement
and exercise often dispelled these pains. He did so, though it
required the help of several men to lift him into the saddle.
The first paces of the horse caused most intense suffering, but
gradually the pain diminished. A thunder-storm now coming
up, the doctor put his horse to the top of his speed, which
caused him to arrive home in a great perspiration, but entirely
free from his pains.

Mechano-thera;.)ist8 will see nothing very remarkable in this
case, for the words, ‘‘Arise and walk ! ” may be confidently
said to anyone suffering from a recent neuralgia who will but
submit to treatment; the power of motion returning almost
invariably after the first application.

Very energetic measures are, however, indispensable.
Neither stroking nor rubbing will do. The muscles must
be pinched, kneaded, and hacked to obtain benefit. As it
would be cruel to begin at once with such vigorous proced-
ures, the gentler measures must be used at first, increasing
the force gradually in order to accustom the patient to the pain.
But mechanical manipulations alone will not suffice. Passive
motion is absolutely necessary, and the immediate adoption of
active motion is still more indispensable. This, the most
painful of all the forms of treatment used, would undoubtedly
alone sufliice, but we will find very few patients who can so
control their feelings as to resort to its employment at once,
before they have become used to the pain by previous manipu-
lation and passive movements.

In Stromeyer’s case the force of circumstances replaced the
hand of the masseur, and who knows, had the thunder-storm

166 TBEATHENT OF UUSCULAB BHXVMATISK.

not forced the doctor to urge hie horse as he did, whether he
would have arrived home so entirely free from pain.

Begarding the pathogenesis of muscular rheumatism,
Busch, in accordance with other authorities, admits that we
have no certain knowledge on the matter. And while he ex-
presses himself against the idea of the disease depending upon
inflammatory exudation — on account of its disappearing with
such suddenness — ^yet he admits the possibility of its depend-
ence upon partial coagulation of the contractile muscle
elements. This view seems, indeed, to find support in the
marvellous results obtained through mechanical means, which
not only generates heat within the muscle substance, but
causes molecular changes to occur there as well.

The modus operandi of treatment is practically the same for
all forms of myalgia — whether it be for lumbago, or “stifiF
neck,” or for those cases where nearly every muscle in the
body seems involved.

In treating lumbago, the patient is made to lie upon his
belly, and the back is then examined for those painful areas
which reveal the location of the muscles affected. Sometimes
the points of greatest tenderness will be found at a little dis-
tance from the spinal column (sacro-lumbalis muscle), or they
may be close to the vertebrse, in the angle between the trans-
verse and spinous processes, occupied by the longissimus dorsi
and spinalis dorsi (Fig. 60). The pain may be either super-
ficial, or it may be so deep-seated as to incline one to believe
the very deepest muscle layer of all— that of the multifidus
spinse — is involved.

In the beginning gentle stroking only should be employed.
When used to this, the patient should be subjected to pressing
and kneading, mildly at first, but later with all possible forc^
And when the pain is deep and the muscles well developed,
the knuckles and fists, reinforced by bearing the weight of the
body upon them, will have to be brought into play to effect
our purpose. Pressing must be carried on both upward and
downward along the side of the spinal column. Every few
minutes the patient should be allowed a short rest.

The form of pressure known as “ rotatory pressure ” (see
page 58) is often of great assistance in these cases, and should

*FB]EATHXKT 07 UnsOULAB BHEUMATISIC. 16t

168 TBEATMENT OF MUSCULAR RHEUMATISM.

be performed with the knuckles and fists. After having gone
up and down the painful places several times in this way-
hacking should be begun, using the edge of the hand, held,
of course, parallel to the vertebral column.

A good knowledge of anatomy is nowhere more essential
than in the treatment of lumbago. A single blow from a
powerful arm, upon the sacro-lumbalis in its upper part, is
quite capable of fracturing one or more ribs; hence, in going
over these parts we must content ourselves with quite mild
procedures, such as rubbing and pressing, or very gentle tap-
ping. Over the muscles lying between the transverse and
spinal processes, however, much force may be expended, care
being taken to avoid striking the bony prominences of the
spine, sacrum, or crista ilii. In cases where the lumbago does
not involve many muscles, fifteen minutes to half an hour will
be all that is requisite for the various procedures.

Pain on inspiration, which sometimes accompanies lumbago,
implies involvement of the serratus posticus inferior, and as
this muscle is covered by the sacro-lumbalis it will be reached
in executing the manipulations just described.

The mechanical manipulations having been completed, pas-
sive motion is next to be undertaken — the patient lying in bed.
First, the knees being bent, each thigh necessarily is flexed
ten times upon the trunk. Second, the patient, while in the
horizontal position, is directed to turn over first ten times
toward one side, then ten toward the other. Third, the
patient being seated, the physician grasps him by the shoulders
and bends the body as far forward as possible.

Active movements are now in order, for, on the completion
of the foregoing, the patient will find himself able to stand,
which before he was incapable of doing on account of the
pain the effort caused.

The following exercises to be performed, the patient stand-
ing:

Body-bending — forward, backward (Fig. 51), and sideways
(Fig. 54).

Body-circling (Fig. 52) and stick-stepping (Fig. 53).

The attendant may, by cooperating with the patient, help to
emphasize each movement as it is made.

TREATMENT OF MUSCULAR RHEUMATISM. 169

After all these exercises have been completed, the patient,
who a short time before was practically helpless from pain

Fig 51. Fig. 62.

and stifthess, will be able to dress himself, to sit down, to bend
over, — in short; to pursue the daily business of life. A little

Fig. 63 Fro. 64.

pain may still be experienced for some hours, but by the fol-
lowing day this will, as a rule, have disappeared.

170

MECHANO-THEBAPY DURING FEVER.

It is very important for the physician to have the
assurance and boldness necessary to compel persistence in
the treatment, in spite of the pain and agony it causes.

In those cases where lumbago results from the rupture of
muscle fibres, as occurs for instance from attempts to lift
excessive weights, or from a sudden rotatory movement of the
trunk, the treatment for the first few days should be that
recommended for a sprain. Rubbing, pressing, and kneading
must be resorted to, the mobility of the muscles being grad-
ually restored as the extravasation is removed. The severer
forms of manipulation, as poking, pinching, and hacking, are
not advisable, and active motion should be postponed until the
torn muscle fibres have been replaced.

TREATMENT OF TORTICOLLIS RHEUMATICUS (STIFF-NECK).

This trouble is substantially identical with lumbago. The
muscles aflfected — the sterno-cleido-mastoid, and trapezius —
are first gently stroked, then successively pressed, kneaded,
and mildly hacked. Then follow movements of the head —
backward, forward and to either side (each ten times), and
finally rotation, performed first passively, and then by the
patient himself, the doctor helping a little, perhaps.

All these procedures cause great suffering, but the patient
will be repaid by the fact that his trouble will usually be
cured at a single sitting.

ON THE APPLICABILITY OP MECHANO-THERAPY DURING
THE PRESENCE OF FEVER.

All authors agree in regarding the existence of fever as a
contra-indication to mechanical treatment. As soon as this
condition appears, treatment should be suspended, and not
resumed until it has disappeared.

In those cases of acute myalgia and neuralgia which can
be indubitably traced to the effects of cold, we will find, how-
ever, that a continuance of the mechanical treatment is one
of the surest means of dissipating the accompanying fever.
It is, of course, of the greatest importance to be absolutely

MECHANO-THERAPY DURING FEVER.

171

certain that the simultaneous appearance of the pains and
fever is not a mere precursor of some acute disease.

Not infrequently one meets with cases which seem to be
made up of a combination of myalgia and neuralgia, and it
is often claimed that these cases soon get well of themselves,
without any treatment whatever. The terra ‘‘soon,’’ how-
ever, is very elastic. In place of it mechano-therapy is able
to substitute a more precise one, i. e., twelve to thirty-six hours.
By mechanical treatment we are able to arrest the disturb-
ances of nutrition in their incipiency and, with them, the
resulting pain, fever, and loss of muscular function, and also
to prevent at the same time the disease from extending or
becoming firmly rooted. It is thus that a patient may be
preserved from what might otherwise have possibly resulted
in months, or even years, of severest pain and disability.

Case VII. — C. S., aged eighteen, domestic, was sitting, in
December, 1882, in the hot tap-room of a tavern, near a door
that was constantly being opened and shut, so that every few
moments she was exposed to a draught of cold air from
without. The following morning she had a temperature of
89.5° C. [103.1° F.], with a pulse of 132, and well-devel-
oped bilateral cervico-brachial neuralgia. There were puncta
dolorosa in the supraspinous fossa of the scapula, on the acro-
mion process, and internal condyle. Over the whole area of
distribution of the cervical and brachial plexuses the skin was
so extremely sensitive that even the gentlest touch caused
her to cry out. The distribution of both sciatics, as far
down as the popliteal spaces, w^as affected in the same way,
the points of exit of the nerves, as well as the origins of the
gluteal muscles, and the back of each thigh, being especially
tender. In addition there was bilateral torticollis.

In spite of the presence of fever, mechanical treatment was
at once begun. By proceeding very gently in the begin-
ning, I accustomed the patient (who cried and complained
constantly) to the unavoidable pain. I then gradually in-
creased the force, using pressure, kneading and hacking, and
followed these with the employment of passive motion, allow-
ing a short pause every three or four minutes, the whole

172

ANJESTHESIA AND H YPE RiESTHESIA.

being continued about half an hour. This was in the morn-
ing — the patient being unable to leave her bed — and at noon
and in the evening I repeated the manipulations for ten min-
utes each time.

The next morning temperature and pulse both were normal,
and the hyperfesthesia reduced at least one-third. Treatment
was repeated and the patient forced to get up and dress,
though she declared herself unable to do either on account of
loss of power. In truth, she was scarcely able to get down
stairs, and the muscles of the shoulder and arm too seemed
nearly powerless. Nevertheless, toward midday she expressed
herself as being better able to move her limbs so that no
further mechanical manipulation seemed called for. She now-
improved steadily, for with every hour she busied herself
more and more with her work, and had more frequent occa-
sion to go up and down stairs. The hypenesthesia also dimin-
ished. By the third day it had disappeared entirely from the
buttocks and thighs, but lingered, however, until the fifth day
over the supraspinous fossa, the deltoid, and internal condyle.
Still, we can claim that within twenty-four hours she was
able to be at work again.

Chronic and so-called “ wandering ’’ myalgias are treated
on the same general principles as the acute.

MECHANICAL TREATMENT OF ANESTHESIA AND
HYPERESTHESIA.

Since these conditions of disturbed function are probaby
due to some alteration in the chemical or molecular structure
of the nerves, it would seem not unlikely that they might
possibly be removed by the molecular changes which
mechanical measures necessarily bring about. Practice has
proved this hypothesis to be true, no matter what the variety
of dyssesthesia; whether tactile, thermic, algesic, or all com-
bined. The excellent effects of stimulating ointments, sina-
pisms, medicinal* baths, electricity, and cold douches upon
anaesthesia are well known; how much more efficient, there-
fore, must not mechanical treatment be !

In both anaesthesia and hyperaesthesia the areas involved

ANAESTHESIA AND HYPER-ESTHESI A.

173

must be pressed, kneaded, pinched, and, finally, mildly hacked.
Even when the trouble depends on some central disease,
much good may still be obtained, as was shown by a case re-
ported by me elsewhere.^

This case, when I first saw it, presented all the more ordi-
nary symptoms of tabes dorsalis. A moderate amount of
ataxia, together with lancinating pains, and gastric crises, and
very extensive ansesthesia of both buttocks existed. When
first taken ill — September, 1879 — with sudden paralysis aflfect-
ing the abducens nerve, the patient had, in consequence of
the differences of opinion which arose regarding this unusual
form of paralysis, become well known as an “ interesting
case” among the prominent oculists of Vienna, and, if I
mistake not, he is alluded to by N. Weis^ in his monograph
on tabes.

The gluteal anaesthesia became very burdensome to the
patient, inasmuch as the tactile and temperature senses were
both entirely lost. lie could not tell whether he was sitting
upon a cold stone, or upon a seat upon which the hot sun had
been shining (indeed, cold objects often made the impression
of hot ones) ; similarly he was unable to distinguish between
a hard and a cushioned seat.

I well knew that anaesthesias occurring in conjunction with
neuralgias, especially those associated with sciatica and limited
to certain cutaneous areas on the thighs, were curable by
massage. So in spite of the generally recognized dictum, that
mechano-therapy is of no avail in tabes, I determined, in view
of my experience, to give it at least a trial. I began, therefore
— very gently and cautiously at first, of course — by letting the
patient lie face downward on the bench, and manipulating
him for five minutes daily with hacking, deep pressure, and
rubbing of the affected parts with the fist — longitudinally,
transversely, and with a circular motion. As very little
force was used the patient suffered no pain whatever. In
twelve days the anaesthesia (of five months’ standing) had
entirely disappeared.

1 Schreiber : Massage in the treatment of the aneesthesia of tabes dorsalis. Wiener med. Presee,
1881, No. 10.

* Weiss : On Tabes Dorsalis. Wiener Elinik, 1880, page 172.

174

AN-®STHESIA AND HYPERJESTHESI A.

The patient, who was a highly intelligent gentleman con-
nected with the University, kept a diary in which he noted
the effects of treatment upon himself. The following is a literal
transcript :

“ Nov. 11, 1880. To-day massage of the buttocks was
undertaken for the first time.

“ lUh. During the past two or three days I have experienced
an unpleasant feeling of tension in the parts massaged, inter-
fering with walking, and especially with going up and down
stairs.

“ 18th. The feeling of tension is disappearing, locomotion
is easier, and there seems to be a slight increase in muscular
power.

“ 19th. The lack of sensibility is disappearing, so that now
on sitting down I can feel what I am sitting on, whereas,
heretofore, it has always seemed as though something were
interposed between me and the object sat upon.

“ 20th. The ‘‘ dead ” feeling in the buttocks is disappear-
ing, and sensibility noticeably increasing. When I sit down
now, I am aware of the presence of the seat, and can tell
whether it is hard or soft. Formerly I felt nothing at first on
seating myself.

“ 22d. The natural sensibility of the parts, which disap-
peared last June, has returned, so that I can now distinguish
the lightest touch, where formerly I scarcely felt the hardest
pinching.

“23d. To-day, the ‘dead’ feeling having disappeared
entirely, massage, which has been continued for the past
twelve days, was stopped.”

These are the naked facts, and in spite of all the scepticism
which is advanced against new therapeutic measures, I hardly
like to assume that chance was the important factor in this
case, for I think the future will show that the means I used in
this instance will find equally suitable applications followed by
equally happy results in other cases of tabes.

The case of the patient Mangeant (case, p. 131) is a striking
illustration of how, during the use of mechanical treatment,
and indeed, in consequence of it, the anaesthesia accompanying
neuralgia may become changed to hypereesthesia of the severest

TEEATMENT OF ARTHRITIC NEUROSES.

175

kind, and of how this in turn may give way to normal sensi-
bility if treatment be continued long enough.

So far, no demonstrable anatomical lesions have been dis-
covered in the cases of loss of tactile sensibility dependent on
spinal disease.'

Turck was the first to show that anaesthesia of a mild degree
could be removed, simply by the use of friction alone. At the
same time he expressed the opinion that the effects following
the inunction of various salves and liniments were largely
due to the mechanical effects of the incidental rubbing. The
cutaneous anaesthesia in the case just described, was un-
doubtedly combined with considerable loss of the muscular
sense, inasmuch as in addition to the absence of perception of
touch and temperature, the patient was unable to form any
conception regarding the resistance presented by the object
he sat upon. Simple rubbing of the skin alone, therefore,
would hardly have sufficed to restore the muscular sense; for
this, manipulations affecting the muscles in their deepest parts
were necessary.

TREA^TMENT OF ARTHRITIC NEUROSES.

In the group of arthritic neuroses must be included that
variety to which Brodie gave the name of hysterical, because
four-fifths of the cases he observed occurred in hysterical
women belonging to the upper classes. Still, the disease
may occasionally be met with in women otherwise healthy,
and also in men. Berger^ is inclined to regard the malady
as essentially an arthritic neuralgia. Indeed, all authors, from
Brodie down to Esmarch, agree that this disease, involving as
it does the capsular and cutaneous nerves of the joint, is to be
classed among the hypersesthesias and neuralgias. Berger
has sought to trace a resemblance between this disease and
neuralgia proper, and while it is true that in it vaso-motor
and motor disturbances are seldom absent, still it is rare for
the pains in the joints to radiate along any particular nerve
trunk as in typical neuralgia.

1 Erb, in Ziemssen’s Cyclopiedia.

2 Berger on arthritic neuralgia. Berliner klin. WochenBchrift, 1873, Nob. 23 and 24.

176 TREATMENT OF ARTHRITIC NEUROSES.

It has happened that for the relief of unbearable arthritic
pain, amputation of the corresponding limb has been resorted
to. Yet the subsequent examination of the affected joint
showed the complete absence of any anatomical changes what-
ever, thus demonstrating beyond dispute that joints, like muscles
and viscera, may be the seat of such severe neuralgia as to lead
to the belief that serious inflammatory process must exist.

The knee and hip are the joints oftenest involved, and
women are more frequently aflfected than men. It is a con-
dition generally dependent on a neurotic tendency, either
congenital or acquired, and is very frequently associated with
chlorosis, ansemia, menstrual disturbances, and various hyster-
ical manifestations. Rosenthal reports its occurring together
with prolonged masturbation. It has also been known to
follow seemingly slight injuries. Esmarch mentions as causes,
falls while dancing and skating, or from a horse, and contu-
sion of the knee with subsequent bloody effusion into the joint.
In some cases it has been known to follow acute general
diseases.

Billroth^ distinguishes four varieties of arthritic neurosis :

1. Those following comparatively slight injuries.

2. Those which remain with some slight effusion after the
cure of a spontaneously originating inflammation.

3. Those which have been preceded by neither inflamma-
tion nor injury, and which yet on walking cause great pain,
(especially in the popliteal space).

4. Those cases in which the pain, at first only simulated (as
in hysterical or hypochondriacal cases), becomes finally such
a fancied reality and so dreaded, that the use of the limb is
finally abandoned.

All of these cases may be complicated by the occurrence of
contractures and cramps, the latter being sometimes epilepti-
form in character.

Billroth grants that possible benefit may be derived from
massage applied in the first and second categories, but doubts
its efficacy in the third and fourth groups, where he says

1 Billroth : Zur Dlscuasion tlber einige Zeit. und Tageafragen. Wiener med. Wocbenachrlft,
1876, No. 46.

TREATMENT OF ARTHRITIC NEUROSES.

177

psychological, rather than surgical, acumen is required to
determine whether pain is actually present or not.

He also discusses the likelihood of local antemia of the bone
being the cause of pain. We know — he says — that cerebral
aneernia causes headache, that ansernia of the lingers occurring
when the hand is ‘‘asleep” or has been held in cold water,
causes a tingling, and that sudden thrombosis [embolism] of
the larger arteries gives rise to intense pain in all the parts
lying below the obstruction. Why may we not assume the
occurrence therefore, in individuals whose arterial calibre is
small (as in chlorotic, ansemic, and hysterical persons), of local
circulatory disturbances, and among these, of local ischaemia
of certain bones ?

In accordance with this theory, Billroth explains the success
of massage in these cases as due to the increased circulation
which it produces in the part. He at the same time attributes
much importance to the influence of the hearty cooperation
on the part of the patient, and to the impression made upon his
or her mind by the novelty of the treatment, and by the per-
sonal influence which the masseur exercises. Nevertheless, in
concluding his interesting elucidation of the subject, he
awards every credit to mechano-therapy, dwelling on the
favorable results observed by him during its use at his clinic
— results which in many cases far surpassed his expectations.

This was in 1875. At that time his convictions were un-
settled by the conflict existing between the observation of his
own undoubted successes, and his well-founded scepticism on
the authenticity of the miraculous cures which were being
constantly reported. Latterly his views seem to have changed,
for he has since himself performed nerve-stretching by the
bloodless method in several cases of neuralgia.^

An interesting report by Mosetig^ on the cure of a case of
torticollis by stretching the spinal accessory nerve, and the
numerous accounts by others of the success attending nerve-
stretching, all combine in justifying the assumption that certain
forms of neuralgia (more especially the idiopathic) are the
result of molecular changes occurring in the nerve elements

1 Billroth : A case of nerve-stretching. Allegem. Wiener med. Zeitung, 1881, No. 48.
8 Mosetig von Moorhof : Wiener med. Presse, 1881, No. 27.

178 TREATMENT OF ARTHRITIC NEUROSES.

themselves, and that some fresh change, such as is initiated
by the operation of stretching and other forms of vibration,
has the power of restoring the nerve to its normal condition.

The mere fact of nerve-stretching having proved unsuccess-
ful in tabes would not in the least militate against the bene-
ficial results of molecular change when applied to neuralgia,
for in the former disease definite anatomical lesions have
occurred in the posterior columns, while in the latter no struc-
tural alterations whatever have so far been discovered in the
nerve-trunks.^ Besides, the difference existing between the
sudden stretching of a nerve trunk, and the vibration pro-
duced in the end-plates of its many thousands of terminal
branches, such as mechano-therapy effects, must necessarily be
very great, and this difference of application is no doubt fol-
lowed by equally varying results. For while in sudden
stretching, the desired end is sought to be obtained at once,
mechanical treatment seeks to attain the same result by the
summation of many small successive influences.

The joints are readily amenable to mechanical treatment.
Cartilages and synovial membranes can be rubbed against one
another — at first quite gently, afterward vvith more force —
while the soft tissues around the joint are capable of being
manipulated in various ways. By these means vibrations are
no doubt produced in the nerves, but the exact effect these
have in stimulating circulation it is hard to say. Still, one
cannot help being impressed with the idea that the beneficial
effects are due very largely to vibration and to the consequent
molecular changes, for it is a well known fact that neuralgias
of the trigeminus, a nerve which, on account of its being
spread out over a bony substructure, offers very little chance
for manipulation and consequent vibration, are the most difli-
cult of all to cure.

For the really successful treatment of these cases a large
amount of moral influence must be added to the mechanical
treatment. Each patient must become the subject of a special
psychological study for the physician. At first gentle manipu-
lations of all kinds may be employed, increasing the force with

1 The author evidently has overlooked those neuralgias which are the result of inflammatory
changes occurring in the connective tissue forming the peri- and epi-neurium, — T bans.

TREATMENT OF PALSIES,

179

which they are executed as the case progresses. Then passive
motions (flexion, extension, and rotation) should cautiously be
tried, and these, too, gradually augmented. Next active
motion of the corresponding sound joint should be tried, and
the patient narrowly watched, when he will soon be ob-
served to unconsciously perform the correlated movements
with the ailing limb. He may then be directed to execute the
same movements with the latter alone. Finally, exercises first
without, then with apparatus are to be employed.

I know of several patients entirely cured by these means,
who for a long time had no use whatever of the affected joint.
Personally, I have treated but one case successfully. This
was of a lady, thirty-five years old, belonging to the richer
class, who had been unable to walk for two years on account
of pain in the right knee, though at no time had there
been any signs of inflammation. The patient had never borne
children, was well nourished, and gave no evidences of being
inclined to hysteria.

Continuous treatment lasting four months permanently
removed both the pain and the disability.

TREATMENT OF PALSIES.

In treating palsies we must, of course, necessarily exclude
all those forms the removal of whose anatomical cause is a
recognized impossibility. In fact, paresis^ and not paralysis, is
the only form at all amenable to mechanical treatment, though
not necessarily more so to this agent than to electricity or
hydrotherapy. Within the past few years many cases have
been treated with all three simultaneously, where any one
alone would not have sufficed. Though why in some cases one
form of treatment should be more successful than another has
as yet remained undetermined.

In applying mechano-therapy to these cases it will be found
useful to employ the same procedures already recommended
under neuralgia, except that they should be more gently exe-
cuted. In consequence of treatment, the affected muscles
become more thoroughly permeated with blood, while the

180

TREATMENT OF PALSIES.

severer manipulations, like pinching, hacking, etc., produce
reflex stimulation of the motor tracts.

Passive as well as active motion — no matter how imperfectly
the latter may be performed — should be gone through daily.
Much patience and perseverance will- be required, for progress
is but too often so exceedingly slow as to be all but inappreci-
able, except after the lapse of weeks. Some cases which seem
to remain stationary for a long time, suddenly begin to im-
prove and then progress with marvellous rapidity.

It is advisable for the physician to superintend the active
exercises personally at least once a day. It often encourages
a patient to note the doctor taking enough interest in his
case to see that the directions are carefully followed, where
otherwise he might become disheartened by the slow progress
he seems to himself to be making. In hysterical cases, the
physician’s personal attention is particularly desirable.

In performing active motion it is always well to set the
patient a definite task on some of the apparatus. If he is
ordered, for instance, to raise his arm as high as a certain peg,
or to place his foot upon a certain rung, the effect produced
will be entirely dififerent than if he had merely received
general orders to execute movements of raising the limbs. In
the former instance the brain, according to Du Bois-Reyraond,
is also forced to participate.

The mode of action of mechanical interferences is analo-
gous to that by which Erb^ explains the action of electricity
upon paralysis.

This distinguished neurologist holds that an electric, or
any other powerful stimulus applied to a motor tract, is capable
of overcoming those pathological resistances which exist in
the pathway of the stimulus, and of thus forcing, as it were,
a channel for the conduction of motor impulses to the muscles.
The obstruction which volition alone was unable to over-
come having been removed by force, the impulses of the will
are now free to travel along their wonted paths again, and, as
a consequence, motility, though perhaps incomplete, returns.
This is the reason why, after the application of a powerful

1 Erb ; Diseases of the Nervous System. Ziomssen’s Cyclopeedia,

TEEATMENT OP PALSIES.

181

electric current, a certain degree of voluntary motion has been
observed to return, often quite suddenly. It seems not improb-
able, therefore, that the continued application of a mechanical
stimulus would finally result in a permanent removal of the
obstruction existing to volitional impulse, and so lead to cure.

Erb, it is true, does not lay much stress on the value of
mechano-therapy in the treatment of paralysis, recommending
it only as a means of perhaps hastening a cure already begun,
but this misapprehension is no doubt based upon a lack of
appreciation of the powerful eftects exercised by mechanical
procedures — effects certainly equal to, and, indeed, in many
instances, far more efficient than those produced by the faradic
current.

The value of the Swedish methods is nowhere more strik-
ingly illustrated than in the treatment of palsies. Ordinarily,
when active motion has been prescribed, all attempts to give
particular exercise to the paretic muscles are rendered nuga-
tory by the simultaneous action of the antagonizers, which,
from their physiological integrity, easily overpower the weaker
muscles. It will, therefore, be the task of the physician to
present such resistances as will successfully eliminate this
antagonization and allow the paretic muscles to contract.
This end can be accomplished most readily by means of various
mechanical apparatus, at the same time the patient’s conveni-
ence will be better suited, inasmuch as he can go through
bis exercises alone, without waiting for assistance from the
physician. Besides, in an apparatus the weights wilt form at
all times a definite measure of the gain in muscle power which
is going on. It will, however, be found better on the whole
to treat this class of patients, firstly, in hydropathic or gym-
nasial establishments, for only a few can go to the expense of
buying costly apparatus; secondly, medical supervision is
highly desirable; and, lastly, because hydrotherapy is a most
useful adjunct to treatment.

182

TREATMENT OF NARCOTIC POISONING.

MECHANICAL TREATMENT OF OPIUM, MORPHINE, AND
CHLOROFORM POISONING.

Mechano-therapy finds one of its most practical applications
in the treatment of narcotic poisoning, whether resulting from
prolonged misuse of this class of drugs or from unusual
sensitiveness to relatively small doses.

Erb is of opinion that narcotics — wliose chief force is ex-
pended upon the centres of consciousness and volition — act,
most probably, by being conveyed in the blood to the nervous
and muscular systems, and there causing either acute disturb-
ances of nutrition, or chronic disease of different divisions of
the apparatus which determines active — i, 6., willed — motion,
which finally results in abolition of function.

For the treatment of the accidental administration of an
overdose of opium, morphine, or chloroform we possess no
readier or more efficient means than the mechanical, whether
applied in the shape of beating, pinching, or hacking of the
muscles over the whole body, or of repeated strokes on the
palms and soles. We read of cases where these procedures
have been kept up for many minutes and even for hours,
resulting, in the end, in the resuscitation of the poisoned indi-
vidual.

For a due appreciation of these facts, we must bear well in
mind the differences existing between poisoning by chloroform,
and by carbonic acid gas, or by morphine.

It is a generally recognized fact that the lethal action of
chloroform is far more sudden than that of either of the other
two. Long experience has shown that if, in chloroform poison-
ing, the evidences of returning life do not reappear within the
first few minutes after the paralytic symptoms have shown
themselves, death, in spite of every effort, is the almost in-
evitable result. In asphyxiation by carbonic acid gas, on the
other hand, unconsciousness may last for a long time, while
the often death-like coma of morphine intoxication is even
still less dangerous. I have had frequent occasion to observe
eases of the latter : the pulse may be barely perceptible, the
sounds of the heart scarcely audible, and the respiratory move-
ments so reduced that scarcely any thoracic motion is dis-

TREATMENT OF NARCOTIC POISONING.

188

cernible, while, at the same time, the extremities grow cold
and the expression becomes fixed. Still, in spite of all these
apparent evidences of speedy dissolution, there need be no
great cause of apprehension, since the action of the heart and
lungs is not suspended but only reduced to its very minimum.
Nevertheless, the alarm of the patient’s family, as well as the
deep concern of his physician, are not entirely uncalled for —
for cases enough exist to show that there is often no awaken-
ing from this profound sopor.

For these accidents there is no more eflicacious treatment
than the mechanical. It is far superior to the application of
sinapisms, ammonia, or electricity. M. R. Levi^ has collected
a mass of interesting material, from his own and others’ expe-
rience, bearing upon this subject. He cites the case of a
young woman, aged twenty, suflering from nervous asthma,
who, after taking between 0.02 and 0.03 (one-third to one-half
grain) of morphine subcutaneously, showed evidences of the
most profound poisoning. When seen, respiration was very
irregular and superficial, the pulse was thread-like, the surface
had begun to grow cold, and there \vas profound coma. The
administratioi/ of drugs was out of the question. An electric
battery was at once sent for, but pending its arrival Levi
had the palms and soles well whipped w^ith rods. Four per-
sons took part in this, and they plied their task till the per-
spiration rolled from their foreheads!

In a short time the patient moved one leg, then the respira-
tion deepened, and presently she sat up in bed and began to
cry. The flagellation being now suspended, she at once re-
lapsed into her former state, and, if left to herself, would no
doubt have died. But the switching was immediately begun
again, and continued, with occasional short pauses, for more
than an hour. Before resorting to this bastinado, Levi had
tried the application of strong ammonia water to the palms
and soles. This did not even produce redness or warmth, nor
did any ecchymoses follow the beating, although so long con-
tinued and so well applied.

The following similar case is reported by Graves in his

1 M. R. Levi : Della flagellazioDe, Venice, 1877.

184

TREATMENT OF NARCOTIC POISONING.

clinical lectures for the year 1823. Dr. Barrett, of Middle-
town, Conn., was called to see a Mr. Wright Harris, who had
taken one and a half ounces of laudanum with suicidal intent.
Emetics and friction having failed, he procured a few supple
willow switches which he used so successfully and vigorously
upon Mr. Harris’s palms and soles that this gentleman pres-
ently awoke and began to remonstrate at the treatment he was
receiving. As, however, he very soon after sunk again into a
state of profound lethargy, it was necessary to apply another
unmerciful switching to arouse him — a procedure which it
subsequently became necessary to repeat frequently, as coma
reappeared whenever it was suspended for a while. This
treatment was continued, with occasional interruptions, for
eight hours, several persons relieving one another in order that
there should be no relaxation in the severity of the application.
At the end of this time Mr. Harris was declared out of danger.
No ecchymoses appeared subsequently on either palms or soles.

Dr. Barrett is of opinion that only a pain as severe as that
produced by the switching was capable of arousing the nervous
system, and thus preventing a total cessation of all bodily
function — in other words, of keeping Mr. Harris alive.

Dr. Bullar, of Southampton, claims to have saved every
case in which there was suspension of respiration following
chloroform narcosis, by himself and his assistants vigorously
slapping the patient’s body with the palms of their hands. This
was kept up until pulse and respiration were again perceptible,
which sometimes did not happen until as much as ten minutes
had elapsed. In many cases the application proved to have
been so vigorous that the lower extremities particularly were
covered with ecchymoses. Bullar insists that no time should
be lost in trying electricitj" and other useless measures, but
that the mechanical treatment should be at once resorted to
with full confidence as to its efficacy. He states that in several
of his cases the action of the heart and lungs had ceased com-
pletely and beyond a doubt, but that by mechanical treatment
life was once more recalled.

The foregoing, as well as the following cases I have ex-
cerpted from Levi’s work just cited, because they seemed to me
to have a practical value for every physician, as all of us may

TREATMENT OF CHLORAL POISONING.

185

be placed in the position where a knowledge of these valuable
facts may enable us to save a human life.

De Angelo, Levi’s assistant physician at the Ospizio Marino
for scrofulous children on the Lido near Venice, took, in
order to test its effects upon himself, a tablespoonful of some
febrifuge which probably contained false Angostura bark, a
drug containing much strychnine. In half an hour tremor,
nausea, and vomiting set in, together with confusion of intellect,
imperfect hearing and articulation, and difficulty in standing.
These symptoms were followed by delirium, a well-marked
epileptic convulsion with complete loss of consciousness, and
such marked suspension of the functions of the heart and
lungs that death seemed imminent.

Friction, strong sinapisms, douching with cold water, as well
as the external and subcutaneous application of strong
ammonia water, having all been tried in vain, his two col-
leagues in attendance and their two assistants provided them-
selves with switches from a convenient tree and rapidly strip-
ping these of their leaves, applied them most vigorously to the
palms and soles. After diligently persevering for a quarter of
an hour, the le^s were slightly moved for the first time, then,
gradually, superficial respiratory movements appeared together
with intermittent beats of the heart. On the flagellation being
continued for fifteen or twenty minutes more, respiration and
pulsation became entirely normal again, warmth returned to
the surface, and finally consciousness was restored.

TREATMENT OF CHLORAL POISONING.

A case of chloral poisoning occurring in the Cook County
Hospital is reported in the Chicago Medical Journal and Ex-
aminer for November, 1876, by Dr. J. W. II. Meyer. Unfor-
tunately, the dose taken is not stated and many details are
omitted. Meyer merely states that flagellation was instituted
several hours after the drug had been taken, and that, as con-
sciousness returned, electricity and dousing with cold water
were substituted in order to spare the patient’s skin as far as
possible.

Levi gives preference to the use of rods or switches applied

186

SPEAINS.

to the palms and soles rather than to the whole body, and
only when these are not easily obtainable does he recommend
the use of the hand instead.

It is possible that by this time this well-known Venetian
physician, who undoubtedly has kept himself informed on the
progress of mechano-therapy, may have changed his former
opinions, and would be inclined to favor manipulation of the
entire body, especially of the larger muscle groups. This, by
promoting circulation, forces more blood into the muscles,
where, according to Fick, the effete matters whose retention
would react injuriously upon the system are eliminated.

It seems not impossible that the nariiotic in the blood may
also in this way be oxidized and rendered innocuous.

GKOUP II. MECHANO-THERAPY OF SPRAINS, SYNOVITIS AND

TENDO-VAGINITIS, GLANDULAR ENLARGEMENTS, CHRONIC

METRITIS, AND HEMORRHAGIC ENDOMETRITIS.

In treating the diseases classified under Group I. our object
was to effect a cure by reestablishing disturbed circulation, by
rectifying malnutrition in muscles and nerves, and by inducing
molecular changes by means of vibrations. In Group II. we
shall seek to reach our aim by the removal of exudations and
extravasations through the process of forcing them into the
lymph channels after previous crushing and trituration.

Sprains.

The older of the French works (I allude, however, to none
written before 1863) are very full of the treatment of sprains —
in fact, many of them contain little else. Philippeaux de-
scribes, even to the minutest detail, the methods of treatment
in vogue up to his time (1870), with Lebatard, Girard, Milet
de Tours, and Magne, and all these are again repeated in the
work of Weiss.

Each of these physicians had his own particular methods,
and each accomplished the common end in view. The chief
differences between them consisted in one set seeking to attain
a cure quickly by energetic but necessarily painful means,

SPEAINS.

187

while the other, contented with slower progress, used gentler
and consequently less painful measures — just as in treating
neuralgias and myalgias we may, according to choice, proceed
either rapidly or slowly.

Any one, however, who is desirous of curing a sprain by
mechanical treatment in a few days — instead of by rest and
antiphlogistics in two to four weeks as formerly — must not only
be well posted upon the mechanics of the part to be treated,
but must have a thorough knowledge of the capabilities and
limitations of his art as well, and nowhere can he gain a better
idea of the whole subject than by reading Busch’s article in
Ziernssen’s Handbook of General Therapeutics}

A sprain is defined by Busch as the forced excursion of a
joint beyond its normal limit of movement. In consequence,
the articular surfaces on the side toward which movement takes
place are pressed together, and a point of contact is formed
which serves as the fulcrum for the lever which forces apart
the opposite portions of the articular surfaces. In conse-
quence of the gap caused by this separation, a vacuum tends
to form within the joint, but this is prevented by the soft peri-
articular tissued being forced in by atmospheric pressure. At
the same time the tendons and ligaments are violently extended
and may be even slightly torn. The moment the force is
removed, the articular surfaces instantly approximate again,
occasionally including folds of synovial membrane between
them, or displacing the interarticular cartilages when these
exist. The pain caused by a sprain is the natural result of
these mechanical disturbances. It occasionally happens that
the sheaths of the tendons are ruptured, and the tendons them-
selves sprung out of place and over some bony prominence.

Having thus laid down the exact nature of a sprain, Busch
divides, from pathologico-anatomical considerations, the object
to be achieved by mechanical means into two divisions.

1. Eestoration to their normal relations of all the component
parts of the joint. He cites here the practice of one of the
older French surgeons — Ravaton — who, whenever called upon
to treat a recent sprain if swelling had not yet taken place.

1 Vol. V. Smith, Elder & Co., London, and Wm, Wood & Co., Now York.

188

SPBAINS.

had the joint forcibly put on the stretch by two strong men
pulling in opposite directions, while he clasped his hands about
it, locking his fingers, and making firm pressure on every side
in order to force into place any bones that might have become
dislocated. Then, after replacing such tendons as had slipped
from their grooves, he applied a bandage.

This restitution of all the parts to their normal environment
is especially important in joints possessed of semilunar carti-
lages, for they are particularly liable to be displaced by sprains,
and to remain caught between the articular ends of the bone
— a condition called “internal derangement” by English
authors.

2. Removal of the spastic muscular contractions. After a
muscle has been put violently upon the stretch it reacts, and

Fig. 00.

a state of tonic spasm ensues, which is not only painful in
itself, but doubly so in these cases on account of the squeezing
together of the articular surfaces which it causes. This spasm

SPRAINS.

189

may, however, be quick!}’' dissipated by gently rubbing the
muscle.

In treating a sprain of the foot we begin with gentle centri-
petal rubbing, using first the finger-tips, then the whole surface
of both hands (Fig. 55), commencing at the toes and gradually
proceding upward as far as the painful spasm reaches. As the
pain diminishes, more and more force may be employed, and
when the contraction has so far relaxed as to leave the joint
movable, gentle flexion and extension of the foot should be
performed. A flannel roller carried above the ankle should
then be applied. After the second or third sitting the move-
ments of the ankle-joint will generally be quite free and almost
painless. The patient may then be allowed to walk a few
steps. Should this not be followed by an increase of pain the
amount of exercise can be cautiously increased until full use is
reestablished, watching closely all the time for the first signs
of any inflammatory swelling.

Other joints are treated on the same plan. Of course,
mechano-therapy is powerless to restore such accidents as
rupture of ligapients, or the tearing oft* of bony prominences,
as not infrequently occurs in severer sprains. All that we can
do in these cases is to promote absorption of the eft'used blood
by spreading it over a greater area. For restoring the injured
parts, time, and the maintenance of a suitable position, by
apparatus, are absolutely necessary.

Altogether, it would be a great mistake to treat every sprain
by massage or movement, for, when serious complications,
like the above, exist, cure will be retarded instead of hastened
by this kind of treatment. Indeed, if persisted in, it may lead
to chronic arthritis, a result which may well be looked upon
as the greatest danger we have to fear from the use of the
mechanical treatment of these cases. Used with discretion,
however, it undoubtedly leads to a far more rapid restoration
of function than when rest alone is employed.

These are the temperately expressed views of an experienced
surgeon like Busch, who undoubtedly speaks from experience.
As may be seen, they dift*er from the utterances of some
authors, who assure us that every sprain is capable of being
cured in a few hours, or at most days.

190

SPRAINS.

Usually, manipulation is repeated two to three times daily,
it being a good rule to begin manipulating again as soon as
the pain recurs.

According to Philippeaux, recent slight sprains are nearly
always curable at a single sitting, and even in the severer cases
(provided, of course, there is no fracture) four to five sittings
suffice to put the patient on his feet again. The sooner treat-
ment is begun the quicker will be the cure.

Fig. 56.

French authors are in the habit of laying down the most
minute directions for treatment, even to describing the way
each finger of the operator is to be placed, but to my mind,
these pages on pages of description are only tiresome and con-
fusing for the beginner, who, if he has any aptitude for the
subject at all, will learn far more from such general directions
as are laid down by Busch. The same authors assure us that
the Iprnrftst fiytrflvftflfltionfl of blood may be removed in one to

SYNOVITIS, TENDO-VAGINITIS, ETC.

191

three days, by forcibly compressing with the thumb {Scrasemmt
or massage ford), where other methods take several weeks
(Fig. 56). Rizet' recommends massage where there is great
swelling about the joints from contusion. It is only by first
removing the swelling in this way, he says, that the existence
of a fracture can in many cases be determined.

All authorities agree on one thing, and that is that the time
consumed in treating a sprain mechanically is far less than by
the old method of immobilization and cold applications. Thus,
according to the statistics of the military surgeon Mullier, the
average number of days required to cure sprains (most of them
of the ankle) by immobilization was 25.6, while by massage
but 9 days were needed. And Moller,^ who compiled his
statistics from French army records, found results equally
favorable to mechano-therapy. Indeed, not only are all
specialists agreed upon the superiority of this treatment, but
many of the most prominent general practitioners have given
it unlimited praise as well. Trousseau and Pidoux say:
‘‘ C^est une des plus heureuses pratiques, que nos contem-
porains aieut retrouvees,” and German physicians are equally
enthusiastic. Hueter says, its results are truly astonishing,
and adds: ‘‘If, as often happens, the ‘natural bone-setters’
meet with more success in the treatment of joint troubles than
regular practitioners it is simply because the latter are igno-
rant of the rational means for curing these cases.” Cabesse,
Wagner, Gassner, Bruberger, and Korner also give it their
hearty endorsement.

In treating sprains all manipulation must be directed centri-
petally, differing in this respect from Group I. — the neuralgias
and myalgias — where direction is immaterial.

Treatment of Synovitis, Tendo-vaginitis, and Glandular
Enlargements.

The treatment of these affections consists in triturating the
exudation, and subsequently removing the liquified mass by
forcing it into the lymphatics.

1 Smplui du massage pour le diagnostic de certaines fractures. Paris, 1866.

* Du massage, son actione physiologique et sa valeur th6rapeutique, sp^cialement au point du Tue
de I’entorse. Journal de M6decine, Brussels, 1877.

192

SEROUS TENDO- VAGINITIS.

All varieties of synovitis are not suited to mechanical treat-
ment, as, for instance, the purulent, or those that threaten to
become so. Treatment can be most successfully applied to
joints whose synovial capsule is situated near the surface. The
manipulations should always bo directed centripetally.

The knee is the joint most frequently involved, and should
be treated daily for five to ten minutes at a time. Passive
movement always facilitates matters, though months are often
necessary for a complete cure, the time required depending
upon the previous duration of the disease.

Those forms of synovitis which are accompanied by hyper-
plasia of the tissues, will require the most energetic rubbing
and kneading, as well as passive motion (flexion and exten-
sion) to remove the new-formed tissue. The treatment of this
form, contrary, perhaps, to expectation, is not as painful to the
patient as it is in some others.

Serous Tendo-vaginitis; Ciirokic and Crepitant.

In this trouble we seek to remove the synovial excess, which
usually collects slowly and without any inflammatory symp-
toms, by Arm pressure of the thumb.

The crepitant form is distinguished from the simple serous
by the fact of the exudation undergoing a coagulative solidifi-
cation within the sheath; this gives rise to a more or less
grating sound when the tendon is moved. The disease fre-
quently results from over-exertion, and is commonly found in
piano and violin players. Old cases will often prove incurable,*
in spite of the most persistent treatment. I recall a case in
which the exudation was removed by treatment till not more
than one-third of the original mass was left, but this remainder
defied all eflTorts at further removal. It felt to the touch harder
in consistency than before, probably because the soft outer
envelopes of the grains, of which the mass consisted, had been
rubbed oS and removed by the mechanical treatment to which
they had been subjected, leaving only the hard kernels behind.

Treatment — which consists in transverse and rotatory pres-
sure applied with all the force the thumbs are capable of— is

but at the same time

MASTITIS AND TONSILLITIS.

193

exceedingly fatiguing to the physician, but any means less
vigorous would be entirely useless.

The Report of the Hospital of Wieden, for the year 1877,
contains some instructive information bearing on this subject.
Two cases of acute ten do- vaginitis of the hand were cured,
the first in nine, the other in fifteen days, while a chronic case
affecting the tendons of the extensors of the right foot and the
peronei, after having lasted two years, was cured in five weeks.
Two cases of serous bursitis were also cured by massage, in
ten and fifteen days respectively. On the other hand, two
other cases of bursitis, treated by antiseptic incision, required
twenty-five days.

Treatment of Mastitis and Tonsillitis,

There can be no doubt that the resorption of glandular exuda-
tions can be materially hastened by mechanical treatment.

Treatment of mastitis by mechano-therapy was reported
by Bergham^ as early as 1874, and more recently in Prof.
Loebisch’s Medicinish-chirurgische Rundschau for May, 1882,
there appeared an article recommending gentle rubbing and
kneading of the indurated portions for from five to ten minutes.
In quite recent cases, this is said to suffice for the removal of
lumps the size of an egg, but in older cases several sittings,
as ’well as more force will be required. Usually some thick
yellowish milk flows from the gland during the operation.
A case can only be considered cured when the indurated
portion has become of the same consistence as the rest of the
gland. The younger Niehaus^ also reports the rapid cure of
recent mastitis by kneading.

Tonsillar hypertrophy is treated in the same way. In the
tonsils, however, approach is possible from one side only.

Quinart* directs that the finger, previously dipped in pow-
dered alum, be pressed against the tonsils (from the inside) at
first gently, and then with considerable force. This treatment is
followed by the use of an emollient gargle. The whole pro-

1 Bergham och Helledey : Some remarks on the kneading manipulation. Nord. med, Archiv,
vol. 7.

2 On Massage : an Address, etc. Correspoudenzldatt fiir Schweizer Aerzte, 1878.

* Massage des amygdalos hypertroph6e8. Journal de m^decine et de chirurgie, 1879.

194 CHBONIC METRITIS AND PARAMETRITIS.

cedure is so simple that the patient can readily perform it upon
himself after a few trials.

In past years* I have had frequent occasion to see, in patients
frequenting Aussee for the saline baths, the disappearance of
glandular enlargements follow a six to ten weeks’ course of
mechanical treatment, when salt baths and salt pack had been
entirely without effect.

Some of these were old cases of hypertrophy of the sub-
maxillary and parotid glands which had existed for j^ears. On
the other hand, I have every now and then come across cases
where the most persistent and energetic treatment was of no
avail.

My own mode of treatment consists in fixing the gland, or
glandular mass, with the left hand, and then rubbing and
kneading it forcibly with the right, at the same time pressing
and squeezing it laterally with the fingers.

A few remarks upon some of the peculiarities of these cases
may be of use. Thus, in a certain class of cases I have seen
treatment persisted in for six weeks before there was even the
beginning of any improvement. In another class, marked
diminution of the swelling could be noted after a week, then
progress would become very slow, and, finally, cease altogether,
an enlargement still remaining against which all further treat-
ment proved powerless.

Experiences like these have consequently led me to be very
cautious in venturing upon a prognosis, both as regards ulti-
mate success as well as time required.

Treatment of Chronic Metritis and Parametritis.

Of late years uterine diseases have been subjected to
mechanical treatment. Of these, the chronic and hemor-
rhagic forms of metritis only belong in the present group,
while some other diseases of the womb and ovaries will be
treated of in Group III., next under discussion.

The first mention of mechano-therapy ap})lied to the uterus
is by Cazeau^ in 1844, who recommended massage for uterine

1 Trait6 de Tart d'accouchements. Paris, 1844.

CHRONIC METRITIS AND PARAMETRITIS. 195

atony during parturition. I^orstrom^ reports successful treat-
ment of chronic metritis, endometritis hemorrhagica, and pro-
lapsus vaginae by massage. Ilis method consists in first fixing
the parts with the first and second fingers introduced into
the vagina, and then kneading the uterus through the ab-
dominal walls, with the other. In 1878, Asp^ called atten-
tion to this subject by publishing the results of seventy-two
cases treated by him in a health-gymnastic establishment in
Helsingfors. These cases embrace chronic metritis, ulcera-
tions, oophoritis, chronic catarrhal troubles, perimetritis, and
displacements of various kinds.

A. Reeves Jackson,^ of Chicago, gives a detailed account of
his methods. He uses massage in the earliest stages of chronic
metritis, considering it of no use later, when the muscular
tissue has been replaced by proliferated connective tissue.
Recent cases, consequently, oflter greater chances for success.
Treatment should be continued patiently for several months,
the sound being introduced from time to time to test whether
a diminution in size is taking place. He recommends that in
the beginning the kneading should be performed very gently,
and not longer^than eight to ten minutes, gradually increas-
ing the force as well as the time consumed, until the latter
occupies as much as forty minutes. Should pain be com-
plained of only after every third or fourth day of treatment,
massage should be continued until the patient becomes accus-
tomed to it. Occasionally it takes some time to overcome the
sensitiveness of the abdominal walls, but not until this has
been accomplished can massage of the uterus proper be really
undertaken.

Jackson uses three different methods :

1. Abdominal massage, which is entirely external.

2. Abdomiiio-vaginal massage.

3. Abdomino-rectal massage.

Of these, the abdomino-vaginal is the most efficacious. The
uterus being grasped simultaneously from within and without,

5 Traitenient des maladies des femmes par le mastiage. Gaz. hebdom., 187G, No. 3.

* Asp : Massage in chronic uterine disease. Virchow and Hirsch, Jahresbericht, 1879.

8 On massage of the uterus as a means of treating certain forms of enlarged womb. Trans. Am.
Gynecolog. Soc., 1880, vol. v.

196 OHBONIC METBITIS AND P AB AMETBITIS.

is firmly kneaded and moved up and down, and back and
forth, in every possible direction. The other two methods are
only used when this one is rendered impossible by a vagina
too narrow or too sensitive to admit two fingers — one finger
alone being insufficient. An objection to rectal massage is,
that the mucous membrane does not stand the interference
well. Abdominal massage is indicated in cases where the
fundus projects above the symphysis pubis. It consists in
grasping the uterus with both hands through the abdominal
walls, and firmly pressing and kneading it, and at the same
time moving it about in every direction.

In the three cases which Jackson reports (two of them fol-
lowing abortion) the size of the uterus diminished considerably,
while the accompanying symptoms disappeared either entirely
or in great part.

The successful treatment of this class of cases is also con-
firmed by Gussenbauer,^ and the case of a woman, thirty-four
years of age, is reported by Goodell, in which there were retro-
fiexion and incomplete prolapse, causing a train of unpleasant
symptoms, all of which disappeared entirely after he had ope-
rated upon the lacerated cervix and massaged the uterus.

J. Eosenstein,^ of San Francisco, reports the removal by
massage of an enormous retro-uterine haematocele, resulting
from the application of a galvanic current, used for the pur-
pose of inducing abortion.

Greulich® recommends massage for the removal of exuda-
tions remaining from previous perimetritis; only, however,
where all other means have failed. The tumor is to be grasped
with both hands and carefully manipulated.

Busch condemns all attempts at loosening adhesions, which
may remain after peri- and para-metritis, and which often give
rise either to sterility, or to various hysterical phenomena.
He regards them as fraught with much danger, owing to the
liability there is of setting up fresh inflammation.

In Sweden, however, Thure Brandt frequently prescribes
massage for this purpose. An assistant introduces two fingers

> Observations on Massage : An Address, etc. Prager med. Wochenschrift, 1881, Nos. 1, 2, 3.
* Oentralblatt fUr GynMkologie, 1881, vol. xiii.

® On Para- and Peri-metritis. Wiener Klinik, July, 1882.

CHEONIO METRITIS AND PARAMETRITIS. 197

into the vagina and presses the uterus firmly against the ab-
dominal walls, while a second assistant grasps it with his
thumb and two fingers and subjects it to every kind of manipu-
lation calculated to loosen the adhesions.

I have myself repeatedly employed these means in similar
cases, and always with success, never having seen inflammation
follow, but I took the precaution to begin very gently, and
only increased the force when I saw that the treatment was
being borne well.

Together with manipulation I generally use a combination
of passive and active movements, employing thigh flexion
passively while in the horizontal, and actively while in the
erect position, also ‘‘hewing’’ [as though splitting a log with

Fig. 57 .

Fig. 58 .

an ax] (Fig. 57), squatting (Fig* 58), trunk-circling, the back-
ward bend, and turning over in bed. The weights may also
be used. (See Fig. 113.)

According to Busch, these exercises tend to loosen exist-
ing adhesions ; first, through the movements of the abdominal
and pelvic viscera which necessarily ensue; and, second,
through the good eflfects of the generally stimulated circula-

198 CHRONIC METRITIS AND PARAMETRITIS.

tion. Unfortunately, many months of patient application are
needed before any marked results can be hoped for.

There is a certain class of cases — of which the following are
examples — which may properly be included in the present
group, in which the success of treatment depends upon the
mechanical removal of some exudation, though the primary
disease itself might perhaps be more properly classified under
some other heading, or possibly even excluded altogether from
the realm of mechano-therapy.

In 1878, Von Winiwarter' published two unique cases, which
so strikingly illustrate the manifold applicability of mechano-
therapy on the one hand, as well as the dependence of its
successful application upon correct diagnosis and thorough
knowledge of its technique on the other, that it seems worth
while to give a sketch of them here.

The first is entitled neuralgic pain simulating sciatica;
tumor in the lumbar region; massage; restoration of the use
of the leg.’’

A man, fifty-eight years of age, was advised to consult Von
Winiwarter in regard to massage for a severe pain in the left
leg which had resisted treatment for five j^ears, and which for
the past two had kept him in bed. The pain, which was of true
neuralgic character, radiated from the lower part of the back
downward along the outer side of the thigh to the knee, and
even as far as the toes, and also toward the coccyx. The par-
oxysms, which were well marked, lasted two to three minutes
and appeared as often as sixty times a day, alternating with a
dull, heavy aching of the whole limb. They disappeared when
the patient was lying, and were less frequent when sitting, but
returned at once upon standing and attempting to walk. He
had, consequently, during the past two years gone no further
than the distance between his bed and his desk, always requir-
ing the help both of his cane and of a servant.

The motion of a carriage, or a railway coach gave him great
discomfort, especially if he was obliged to let the leg hang
down. His easiest position was a half reclining one, with the

^ Two illustrations of the use of massage in chronic disease of internal organs. Wiener med.
Blatter, 1879, No. 29.

CHRONIC METRITIS AND PARAMETRITIS. 199

leg stretched out. The various physicians whom he had con-
sulted pronounced the case to be one of sciatica.

On first examining the patient Von Winiwarter detected
nothing abnormal excepting atrophy of the left lower ex-
tremity. He was struck, however, with the fact that the point
of emergence of the sciatic nerve was not sensitive, but that
the pain seemed rather to come from a region higher up.
Palpation in the left lumbar region revealed a fiat, slightly
nodulated, and, on its outer edge, sharply defined tumor reach-
ing as far upward as the last rib. It seemed to be deeply
situated beneath the muscles, but owing to the corpulence of
the patient its exact relations were hard to establish. It
was not painful to palpation except at a certain point, where
pressure caused a most sudden and intense pain, and at once
brought on a neuralgic paroxysm. When asked to locate the
seat of greatest pain, the patient invariably pointed to the
thigh and coccygeal region, and never to the tumor. Indeed,
neither he nor his family had any idea of the latter’s existence.
Von Winiwarter made up his mind that this tumor was the
cause of all the trouble, but in regard to its nature he was
entirely at a loss. Examination showed it to be of a tense,
elastic consistency, with a point of doubtful fluctuation in the
middle. No boundary could be felt on the side toward the
spinal column, from underneath the side of which it seemed to
project. The overlying skin was unchanged in color and not
adherent to the parts below. Nothing could be ascertained by
abdominal palpation, owing, as before remarked, to the patient’s
corpulence. Nor did the previous history of the case throw
any decided light upon its possible nature.

For twenty years the patient had had a mild cystitis, for
which, though it gave him no trouble, he went yearly to
Carlsbad. Five years before he had had some febrile disorder,
the nature of which had not been determined, but which had
been accompanied by severe pain in the region of the kidneys,
lasting several days. There was no dysuria, but the turbidity of
the urine was said to have been somewhat increased for a few
days. This illness confined him to bed for several weeks, and
during convalescence the present pains began, which continued
to increase in severity up to the present time.

200 CHRONIC METRITIS AND PARAMETRITIS.

On Von Winiwarter’s taking the case, an analysis of the
urine by Prof. Ludwig, of Vienna, showed the presence of a
trace of albumen, together with some pus corpuscles and
bladder epithelium. No renal epithelium was found.

In view of all the facts ascertainable, the tumor seemed to
Von Winiwarter to stand in close genetic connection with the
left kidney. He supposed it to have begun as an inflammation
in the perinephritic tissues, resulting in the formation of a
mass of exudation, similar to those occurring in the neighbor-
hood of the uterus. This mass — which had begun to soften
in the centre — by pressing upon the lumbar plexus was the
source of the neuralgia; the pain originating in the lumbar,
but radiating to the sacral nerves as well. In this diagnosis
Prof. Billroth, who saw the patient a few days later, concurred.
Both were agreed as to the advisability of employing massage,
not only to reduce the extreme sensibility of the nerves, but to
effect, if possible, a decrease in the size of the tumor.

Treatment was begun on January 14, 1878. At first it
proved extremely painful, but the fact that decided improve-
ment took place served to buoy up the patient’s courage. In
a fortnight the painful points along the thigh had disappeared
and short walks could be taken without aid. The paroxysms
were first reduced to one or two a day, and then, finally, ceased
altogether. Exercise of the leg, in Von Winiwarter’s presence,
by inducing confidence served to dispel the dread of pain,
which still clung to the patient whenever he attempted to use
the limb. Finally, after sixty-four days of treatment, the
patient went back to his home cured. The tumor had been
reduced to a small, firm remnant, in which no fluctuation was
apparent. Hard pressure upon it still caused pain, but no
paroxysm resulted. The patient was able to walk for several
hours at a time every day, and could use the leg in every way
like a normal one. A marked change, too, occurred in his
psychic condition ; his expression, which before had been pro-
foundly melancholic, now vividly reflected the beneficial effects
the cure had had upon his mind.

There are many highly interesting features in connection
with this case. It shows, to begin with, how much caution
must be exercised before making an unqualified diagnosis of

CHRONIC METRITIS AND PARAMETRITIS. 201

“ sciatica.” The absence of the painful point at the exit of the
sciatic nerve was enough to make Yon Winiwarter suspect that
in this case, certainly, he had not to deal with ordinary sciatica,
and had the patient been treated by the methods laid down by
me under the head of Sciatica, without at the same time seek-
ing to remove the tumor, no good effects would probably have
been obtained. If, on the other hand, the tumor had been of
a firm and dense structure, massage would have been useless,
and the knife would then have been the only rational means
of interference.

The various forms of congestive oedemas are also properly
to be ranked in the present category.

The use of pressure by bandaging, so long in vogue, is in
reality but a form of treatment based on mechanical principles.

(Edema of the lower extremities, caused by abdominal
growths, can nearly always be greatly relieved, if not entirely
removed, by persistent manipulation (kneading and rubbing
centripetally) performed once or twice a day for some time.

The manipulation — which is very easily learned— should be
performed with the patient lying or seated opposite the ope-
rator, with his limbs, previously oiled, raised upon a support.
At first the rubbing should be carried on quite gently, later
the force can be gradually increased. It is well to begin at
the toes, rubbing upward over the ankle and up the leg, either
with one hand alone, or with both hands placed side by side,
clasping the limb. Or, the hand being half clenched, the inner
side of the first and second joints of the first finger may be
used. The rubbing and pressing should be maintained equably
and forcibly for from five to fifteen minutes.

In manipulating oedematous abdominal walls, the motions
should be made from above and outward, in a direction down-
ward and inward toward the inguinal region, for the lymph-
atics of the anterior and lateral portions of the skin of the
abdomen empty into the plexus of lymph nodes lying within
the pelvis and upon the internal iliac muscle. This plexus
empties its contents into the superior lumbar nodes, and these
again into the thoracic duct.

Every year I see oedemas arising from the pressure of

202

CHBONIC METBITIS AND PARAMETRITIS.

uterine fibroids, greatly benefited by massage. They are all
so alike that any detailed description of each is unnecessary.

The second of Von Winiwarter’s cases, already alluded to, is
of such unusual occurrence, however, and has such a direct
bearing upon this class of cases, that I give it here.

A woman, seventy-nine years of age, had suffered so greatly
from the dropsy resulting from the pressure of a multilocular
ovarian cyst, that she had to be tapped eight times within
five months. Upon massage of the legs being undertaken by
Von Winiwarter, the oedema diminished, while, at the same
time, diuresis increased. Subsequent massage of the abdomen
for nine months resulted in a diminution in the size of the
tumor — a diminution which, though at first progressive, finally
became stationary. No fresh oedema appeared. Von Wini-
warter being at this period prevented from giving his personal
attention to the case, the massage was undertaken by an inex-
perienced hand, with the result that the old state of affairs soon
returned, only to disappear again, however, when Von Wini-
warter resumed the case — a proof of what has so often been
observed, namely, that the success of treatment depends very
largely on the individual skill and knowledge of the operator.

In his report of the case, Von Winiwarter adds a justification
for the employment of this form of treatment. He instances,
in the first place, the beneficial results obtained by Chrobak in
cases of congestive oedemas arising from the pressure of uterine
fibroids; and, in the second, his own observations upon the
rapid absorption by the ovarian cyst wall of various medica-
ments, like potassium iodide, for example, which a short time
after injection into the cyst reappears in the saliva and tears.
Reasoning from the experience he had had in removing fluid
from oedematous limbs, where its absorption by the blood had
caused secondarily increased diuresis, which finally led to the
entire elimination of the fluid from the body, he assumed that
the cyst fluid, which has a low specific gravity, could be like-
wise removed by mechanical means. While not attempting to
decide the question as to whether the fluid is absorbed by the
lymph or by the bloodvessels, he combats the idea that re-
sorption is not due to the immediate manipulation of the Cyst
itself, but rather to the stimulation of the circulation as a

CHEONIC METRITIS AND PARAMETRITIS.

203

whole, which, by leading to increased diuresis, necessarily in-
volves an increased absorption of the cyst fluid. If this latter
explanation were the correct one, he maintains, mechanical
treatment would be equivalent in its effects to that by diuresis
and purgation, yet it is a universally acknowledged fact, that
the ovarian fluid remains unaltered in quantity, even after the
most vigorous and prolonged use of diuretics and cathartics.

His mode of treatment of this class of cases has been criti-
cised as being connected with a great many difficulties, and
being, at the best, but palliative. But to this he replies by
showing that in this case massage had been of more effect than
repeated tapping, that it had not only prolonged life, but had
made it as bearable as it possibly could be made without
resorting to radical operation.

Von Winiwarter, therefore, regards massage as indicated in
all cases of ovarian cyst, where from any cause operating is
impracticable. He insists, however, on its thorough and
vigorous execution, for a considerable time, if any good results
are to be expected. He goes so far as to recommend it, with-
out fear of injurious results, for any deep-lying abdominal
tumor the nature of which is obscure, even though a malignant
growth or suppurative process be suspected, as well as for all
cases of ascites where it is deemed inadvisable to stimulate the
kidneys by diuretics.

He lays great stress, however, on the fact that for a proper
appreciation of the results it is important that treatment should
be carried out by the attending physician himself, or, at any
rate, by a physician properly instructed. No nurse should be
allowed to treat a patient according to some studied routine,
for the result will only be torture to the patient and discredit
to the whole system.

I cannot forbear repeating here a remark of Von Wini-
warter’s which reflects so well the prejudice which in 1878 still
existed in Vienna in regard to massage. He said : “lam quite
ready to shoulder the responsibility for the mildly comical
aspect which appears to lie in the proposition of treating ab-
dominal affections by fisticuflPs ! ”

204

STIFFNESS OF JOINTS AND TENDONS.

Treatment of Stiffness of Joints and Tendons.

It not infrequently happens that, after arthritis, thickening
of the periarthritic structures, or even adhesion of the articular
surfaces themselves may occur, leading to very considerable
disability of motion. Only by mechanical means can we then
hope to break up the existing adhesions, to smooth the
roughened articular cartilages, and to restore to the ligaments
their former suppleness and elasticity.

All the mechanical interferences used — pressing, rubbing,
kneading, as well as the passive exercises — must be performed
with the greatest care, since it is quite possible to initiate fresh
inflammatory action by injudicious treatment. Within the
first two weeks precaution is doubly necessary, as some indi-
viduals are quite unable to stand the mechanical procedures.
Increased temperature of the joint, fever, severe and con-
tinuous pain may all occur; symptoms indicating that an
obstinate persistence in treatment would certainly lead to
severe inflammation. In these cases a postponement is abso-
lutely required.

The successful treatment of these cases affords one of the
most difficult problems of the mechano-therapist, for it requires
untiring perseverance and patience as well as nice judgment
and all the fruits gained by experience to tide the patient over
the necessary" pain which for months he may be called upon to
bear. And, withal, the guaranty of perfect restoration of the
aflfected joint must never be given, for the degree of use
which may possibly be regained can never be predicted in
advance, because there are cases (fortunately exceptional)
where, in spite of the best of treatment, no success is attained.
As a rule, the longer the existing condition has lasted, the
longer will treatment be necessary, and the more uncertain
will be its result, yet one every now and then meets even quite
recent cases to which it is impossible to restore any but a slight
degree of motion. Success depends not so much on the dura-
tion of the adhesions as upon their extent and firmness.

Treatment should only be begun when all signs of inflam-
mation have entirely disappeared. Some prefer to perform

STIFFNESS OF JOINTS AND TENDONS. 205

massage with the part immersed in hot water or under a hot
water or steam douche.^ I have been accustomed to use both
a warm saline water (such as occurs at Aussee) as well as cold
water in performing massage, reserving, for the sake of com-
parison, certain cases which I treated without either, but my
observations are not yet numerous enough for me to formulate
an opinion on the combined influences of hydro- or balneo-
therapy and mechano-therapy.

When many joints are involved, as may be the case in
chronic rheumatism, the execution of all the diflferent pro-
cedures may occupy an hour or more, and as they are neces-
sarily painful, it is as well to confine one’s self to the manipu-
lation of a single part at each sitting.

The passive and active motions to be used differ from those
employed in treating muscular rheumatism and neuralgias
only in their degree of application. While in the former it is
our object to call forth the greatest possible muscular activity
in order to induce changes in the muscles and their nerves,
in arthropathies, on the contrary, we are forced to proceed
with the greatest possible care. Here the muscular contrac-
tions are only a means toward the end; their action is simply
the mechanical one of causing the articular surfaces to rub
upon each other and thus grind away any existing roughness,
while the motion of the tendons is calculated to loosen those
fibrinous bands of exudation which surround them in the
neighborhood of the aflFected joint. Considerable experience
and judgment are requisite to estimate the force and rapidity
with which the movements should be executed, and, con-
sequently, these cases should never be treated by any but a
physician.

The modus operandi in each case will be indicated by the
mechanism of the particular joint to be treated, which some-
times will be found to be immovably fixed. At first the tissues
surrounding the joint are to be gently rubbed, using in the
beginning the finger-tips only ; later, the force may be increased.
As soon as the part has, in a measure, become accustomed to

I Zienuraon : Mewage with the hot douche and in the hot bath. Deutsche med. Wochenschr., No.
34 , 1877 .

206

STIFFNESS OF JOINTS AND TENDONS.

the pain, the passive motions, suitable to the joint, may be
begun.

The following general precautions should never be lost sight
ot in executing this class of manipulations:

The joint must be supported by the physician’s left hand,
while with his right the passive motions are performed, pro-
ceeding very cautiously in the beginning. The adhesions
existing within and around the joint may be of so firm and
resistant a nature as to readily lead to the belief in the exist-
ence of bony ankylosis. At first, the amount of motion
obtained in the joint will be exceedingly small, but even with
this we will be bound to rest satisfied, for an increase of
mobility often does not begin for months ; in the meanwhile
the patience of both physician and patient will necessarily be
put to a severe test. Nevertheless — keeping the old saying,
that “ constant dropping wears away the rock,” in mind —
treatment must be continued steadily and systematically. The
astonishing results which experienced mechano-therapists often
obtain in cases declared incurable by others, can often be ex-
plained by the consistent and methodical treatment which
they pursue.

In employing passive motion for the fingers and toes it will
often require not a little dexterity to immobilize with the left
hand the joints not intended to be moved. For instance,
should it be desired to flex and extend the second phalangeal
articulation of any of the fingers, the physician’s left hand
will be obliged to fix both the first phalangeal and the meta-
tarso-phalangeal joints. In manipulating the joints crepitation,
caused by the friction of the uneven articular surfaces upon
each other, or by the periarticular exudations, is usually expe-
rienced. Occasionally it is so marked as to be actually audible.
I have found it to be most common in the joints of the hand.

The knee-joint is very often the seat of extensive synovial
exudation in consequence of chronic rheumatism. Eesorption
is to be effected as in synovitis in general, namely, by centri-
petal rubbing, and by pressing and kneading. When, as
is not uncommon, chronic muscular rheumatism is combined
with that of the joints, the muscles will have to be treated as
well.

STIFFNESS OF JOINTS AND TENDONS.

207

Every ten or twelve days it is well to allow our much tried
patient a day of rest. The very anticipation of this holiday
will enable him to endure all the more uncomplainingly the
tortures to which he is unavoidably subjected.

Often in spite of every precaution slight inflammatory
symptoms may present themselves — an indication to cease
mechanical treatment at once. As a rule, rest and antiphlo-
gistic treatment allay the inflammation in a few days, and in
three or four weeks the joint can be manipulated again, and is
usually less sensitive than before.

Case VIII. — Mrs. H. W., aged twenty-seven. Always well
up to her twenty-fifth year. On November 17, 1879, was taken
ill with typhoid fever of so severe a form as to confine her to
bed for three months. During convalescence, and while stay-
ing in a rather damp summer resort in Bohemia, she was
attacked with acute articular and muscular rheumatism, pre-
ceded by pains in the chest, l)ack, arms, and thighs.

On October 17, 1880, high fever set in, which was soon fol-
lowed first by swelling of the carpal joints, and tliv.n suc-
cessively of nearly all the joints and muscles of the body.
The chief seats of inflammation were the i»eriarticular tissues,
the insertions of the extremital muscles, and especially all the
joints of the fingers. The acute febrile stage lasted about ten
weeks. Salicylic acid could not be tolerated, but immobiliza-
tion of the joints gave some relief, and for days both the
lower and the upper extremities lay in splints. There were
glandular enlargements in the neck, axilla?, and groins. A
subacute stage followed the acute, during which the patient
managed to pass part of the time on a sofa, or even sitting up,
but the swelling, stitFness, and pain in the whole motor appa-
ratus still persisted, preventing any but the most limited use
of the extremities.

Massage undertaken at this time (by Prof. Gussenbauer)
could not be continued, as it produced febrile exacerbations,
acute glandular enlargements, and increase of the articular
swelling and pain.

By July, 1881, the patient still could not rise unaided from
a seat, could take only a few steps about the room, and was

208 STIFFNESS OF JOINTS AND TENDONS.

quite unable to go up stairs. Writing, and the use of the
dngers invoked in handling a knife and fork, were still very
difficult. At tbe same time she was 8ut>|ect to an irregular
recurrence of very violent paroxysms ot pain in the limbs,
occasioning much loss of sleep. The urine deposited a thick
sediment; the pulse was increased in frequency; the tempera-
ture had gradually become normal. There were no changes
discernible in the internal organs.

July 10, 1881, the patient, accompanied by her husband
(himself a clinical professor), came to Aussee for treatment.

All joints of the fingers, wrists, elbows, shoulders, hips,
knees, and ankles I found to be involved, the toes only remain-
ing untouched.

In both knees there was an abundant synovial exudation,
quite evident on visual inspection alone, and extending three
centimetres below each patella.

On beginning treatment the time occupied daily was between
thirty and forty minutes, and though causing much pain and
exhaustion, was, on the whole, well borne by the lady, who
possessed much resolution and self-control.

In five weeks the exudation about the patella had notably
diminished in consequence of kneading, while the motility of
both upper and lower extremities had quite sensibly increased.

In six weeks she was able to rise from a seat without help,
and in two months could, without fatigue, take a walk of half
an hour’s duration; whereas, on her arrival, she was barely
able to drag herself from her own room to the dining-room.

Her gait, which had, in the beginning, been lame and faulty
in every respect, improved so, that the progress made from
week to week struck all who saw her. Going up stairs, too —
at one time impossible — was an accomplishment she once more
learned. The use of her fingers at meals as well as for sewing
gradually returned, and she felt herself in consequence not a
little rewarded for all the pain so heroically borne.

The original fixed partial flexion of the forearms still per-
sisted to some extent, the elbow remaining slightly bent. The
sensibility of the joints also, though much less, still continued.
The movements of flexion of the fingers had become much

STIFFNESS OF JOINTS AND TENDONS.

209

freer — still the patient was a long way off from being able to
make a fist.

On the other hand, she was now able to execute the move-
ments of sitting and rising again, kneeling, running, arm-
circling, shoulder-hitting, etc., which at the beginning of treat-
ment were quite impossible.

On leaving, after ten weeks of treatment, she had the satis-
faction of stepping unaided into her carriage, into which she
had formerly to be lifted. Mechano-therapy had, to sum up,
been in her case of the greatest benefit, a fact more especially
appreciated by all who at her home in Prague had known her
former helpless condition.

I am under the impression that treatment was continued in
Prague, without, however, leading to complete restoration.
In the autumn of 1882 the patient spent some time in the
Grotto of Monsumano, hoping to get rid of the remainder of
the joint stiffness. From her husband’s reports I judge her
condition is not yet entirely satisfactory, the pains in the knees
and thighs being especially obstinate, so that she is again con-
sidering the advisability of undergoing mechanical treatment.

I have purposely presented a case in which, in spite of skilled
and continuous treatment, as w’ell as of great fortitude on the
part of the patient, only partial cure was obtained after all, in
order that the beginner, who may have a similar case to treat,
shall not lay his want of success entirely to his own supposed
lack of skill.

In closing my remarks on this class of diseases, I will cite
the opinions of a great surgeon in this connection, which are
the more valuable since they are taken from an article w'ritten
to combat the extreme tendencies of mechano-therapy, and to
relegate it to its proper sphere.^

According to Billroth: “The sequelae of sprains and chronic
rheumatic arthritis” (stiffness and tenderness) “yield so slowly
to the usual means, that we should gladly hail a method ac-
complishing the desired end more quickly.” He closes with
these words : “I can only agree with the opinions of my col-

1 Billroth ; A discussion of some of the surgical questions of the day. Wiener med. Wochenschr ,
1876, No. 46.

210

TEEATMENT OP EYE DISEASES.

leagues Von Langenbeck and Esmarch, that for suitable cases
massage deserves more recognition than it has received in
Germany during the past few decades.”

Tkeatment of Eye Diseases.

In treating the eye on tnechanical principles gentle manipu-
lation alone is the only one of all the various forms of mechano-
therapy available.

Two kinds of manipulation may be used. Either pressure
made upon the eyeball generally, or friction of the lid upon
the cornea.

By means of the first, obstructions existing in the circulatory
channels are removed, and freer outlet given to the humors of
the eye. Exudations can thus be forced out of the eye to be
removed by the general circulation. There can l)e no doubt
that persistent pressure exerted upon the ball for some time
perceptibly lowers, for a while at least, the intraocular pressure.

By friction, fresh inflammation is set up in old organized
exudations, which, on account of the increased supply of blood
it induces, leads to a removal of the deposit. The principle
of this latter effect of mechano-therapy was employed years
ago by F. Jager, Sr., who inoculated blennorrhoeic pus for the
removal of pannus.

According to Schenkl,^ Bonders, at the Ophthalmological
Congress in London, 1872, was the first to recommend knead-
ing for certain corneal affections; but it was Pagenstecher
who first really systematized ocular mechano- therapeutics.
Prom time to time various clinical contributions have been
made by Gradenigo, Chaudin, Petraglia, Just, and Fried-
mann; and Klein^ has summed up our present knowledge of
the subject in a series of recent contributions.

According to the unanimous opinion of the most eminent
oculists, the application of mechano-therapy is suited to the
following diseases of the eye :

i Schenki : Some of the newer points in the treatment of eye diseases. Prager med. Wochen-
schrift, 1882, No. 30.

» Klein : On the application of massage in ocular therapy. Wiener med. Presse, 1882, Nos. 9, 10,
12, 16.

TREATMENT OP EYE DISEASES.

211

1. Conjunctivitis pustulosa. 2. Conjunctivitis marginalis
hypertrophica. 3. Episcleritis subacuta et chronica. 4. All
varieties of corneal opacities capable of being cleared — as
those following pannus, and scrofulous and parenchymatous
keratitis.

Upon Gradenigo’s showing that in the healthy eye the intra-
ocular pressure could be diminished by mechanical pressure
for two to six minutes, this procedure was applied to the
treatment of glaucoma, and its beneficial effect in reducing the
intraocular tension has been confirmed by Wicherkievicz,
Schnabel, and Klein.

Fl«. i>U.

The accompanying drawing (Fig. 59), kindly lent me by
Schenkl, shows the method of applying treatment. Accord-
ing tojthe seat of the trouble, either the upper or lower lid
is fixed by the thumb of the operator placed near its ciliary

212

TREATMENT OF EYE DISEASES.

edge, and then friction is made upon the ball. Pagenstecher
recommends that the lid which is not being used be slightly
retracted from the eye by the unoccupied hand. He employs
both circular and radial friction, preferring, however, the
latter, which is performed by rubbing from the centre of the
cornea outward toward the equator of the ball. In this
manner any given sector of the eye may be treated separately.

Klein employs radial massage for local, and circular for
general lesions, and both he and Pagenstecher direct that the
motions should be performed rapidly, strong pressure being
carefully avoided ; the lid should be made to simply glide
gently back and forth over the bulb.

Klein has attempted to establish the maximum of pressure
which may be employed, by taking as a standard the force
necessary to produce a contraction of the iris sufficiently strong
to retract a prolapsed portion. Schenkl asserts that the em-
ployment of moderate pressure during massage is neither
disagreeable to the patient, nor is it followed by any sub-
sequent signs of irritation. The degree of pressure, he asserts,
should be measured according to the desired effects ; thus, the
removal of purulent effusions from the anterior chamber will
call for a different amount of pressure than when it is desired
to cause, according to Chaudin’s method, the resorption of
portions of the lens.

The rubbing should not last longer than from one to live
minutes, nor should it be performed oftener than once daily,
except in such cases where rapidity of cure is especially
called for.

Pain will only be complained of when iritis exists. Redness
of the conjunctiva usually follows the rubbing and lasts from
fifteen to thirty minutes, except where conjunctivitis exists,
when it may continue for one or two hours. On the whole,
the period of irritation diminishes from day to day.

The best results of ocular massage are obtained in cases of
long-standing corneal opacities, as shown by the following case
of Schenkl’s.

A. H., aged eighteen, suffered for the past seven weeks from
corneal opacity following keratitis parenchymatosa. With the
exception of a narrow peripheral border, the opacity included

TBEATMENT OF EYE DISEASES.

213

the whole cornea, being most dense at the centre. All sorts
of irritants, as white precipitate, calomel, tincture of opium,
hot applications, etc., were used without effect. Rubbing the
eyelid upon the cornea, together with the use of an ointment
of yellow oxide of mercury (0.05 to 2 of vaseline), was then
ordered, and after three applications the opacity began to dis-
appear — first in the centre, then in spots along the periphery
gradually extending toward the centre.

Pagenstecher asserts to have seen good results in old, long-
standing cases, and records cures of opacities that had lasted
for thirty years or more.

Klein was the first to attempt the mechanical treatment of
keratitis in its acute stage, and in one instance he succeeded in
aborting the inflammation after three days treatment, in a
patient in whom a keratitis of the other eye, on a former occa-
sion, had required six weeks for a cure under the old methods
of atropia, hot applications, etc.

With regard to the simultaneous application of ointments
authorities differ. Pagenstecher always uses an ointment of
yellow oxide of mercur 3 % while Klein and Petraglia admit of
none, in order to qbtain results free from any ambiguous inter-
pretation. Schenkl at first used no ointments, but as he found
that the attendance at his clinic fell off* when the patients saw
that they received no medicine of any kind, he returned to the
use of some indiflFerent ointment.

The cases of episcleritis cured in three to ten sittings, pub-
lished by these authorities — Pagenstecher, Klein, and Schenkl
— encourage to the more frequent use of massage in this aflFec-
tion ; the more so as under ordinary treatment the disease
usually lasts several months.

Latterly the mechanical treatment of glaucoma has been
advocated. Klein has formulated the indications for its use.
These are, first, acute and chronic glaucoma, beginning with
inflammatory symptoms and accompanied by increased intra-
ocular tension ; second, cases where sclerotomy and iridectomy
have proved ineffectual ; third, glaucoma accompanied by con-
tinual neuralgia, rendering operation impossible ; fourth,
glaucoma in which operation seems directly contraindicated,
as in the hemorrhagic form.

214 CHLOROSIS, GASTRITIS, PHTHISIS, ETC.

Schenkl is inclined to regard the mechanical treatment of
glaucoma less favorably, except where the disease is secondary.
But he recommends it for the treatment of hemorrhage into
the anterior chamber, and for conjunctival ecchymosis. Klein
thinks it may still prove useful in cases of obstinate ciliary
neuralgia, of blepharospasm, and of supraorbital neuralgia.

Personally, I have had no opportunity to test the efficacy of
mechanical measures upon the eye. I have, however, seen
many cases of supraorbital neuralgia, but have never observed
anything more than temporary relief afforded them by massage.

GROUP III. JVIECHANO-THKRAPY OF CHLOROSIS; CHRONIC
CATARRHAL GASTRITIS; PULMONARY PHTHISIS; HYS-
TERIA; HYPOCHONDRIA; AND DIABETES MELLITUS.

In all the above conditions, which, with the exception of
chronic catarrhal gastritis, depend upon some congenital
morbid tendency, the aim of all treatment is to modify, both
qualitatively and quantitatively, the processes of nutrition. The
uselessness of all medication in these diseases has long been
recognized. Quinine and iron alone have retained their repu-
tation as general tonics ; still, even these remedies occupy but
a secondary place compared to change of climate, sea bathing,
hydrotherapy, milk cures, etc. Neurasthenia, hysteria, and
hypochondria — all three so intimately related — are often a
favorite field for the application of electricity, an agent which
in the last few years has come into such active competition
with mechano-therapy. As stated before, mechano-therapy
can do but little in these cases unless seconded by a treatment
aiming at a general elevation of the tone of the body as a
whole.

The influence which mechano-therapy exerts in the cure of
these cases will vary considerably. It is smallest, perhaps, in
chlorosis and chronic gastritis, where it is forced to share the
honors with hydrotherapy, while it is greatest in certain forms
of phthisis, though here much of the beneficial result must be
laid to the effects of a simultaneous resort to high altitudes.

It would be hard to establish any definite data regarding its
effects upon neurasthenia, hysteria, and hypochondria, for with

CHLOROSIS, GASTRITIS, PHTHISIS, ETC

215

the multiform symptoms which these affections present, the
success of raechano-therapy in any particular case will entirely
depend on the class of symptoms which occur. Sometimes a
great deal may be accomplished, in others very little.

For the treatment of this group of diseases considered as a
whole, the following physiological principles should be kept
in mind.

The muscles being the chief site of chemical change occurring
in the body, stimulating and increasing their action leads to
increased oxygenation of the blood; to greater combustion
of oxygen and elimination of carbonic acid ; to increased
metabolism and consequently to greater desire for food and to
better digestion; to production of more and better blood; to
improved nourishment of the nervous system; to an increase,
both in number and strength, of the muscle fibres; to the
endowment of the whole body with vigor and elasticity, and to
a consequent revival of all the mental faculties.

While these then are the principles of treatment, their
application to the individual diseases of which the group is
composed will require considerable variation.

In chlorosis a^d phthisis, for instance, active movements
take precedence over mechanical manipulations, while chronic
gastritis will demand the use of both forms. In neurasthenia,
hysteria, and hypochondria, all forms — passive, active, and
mechanical — are called into play, first one, then another pre-
ponderating.

In chlorosis the bloodvessels are both thin-walled and of
narrow calibre, and we must seek to strengthen them through
active exercise, which stimulates cardiac activity and increases
the blood pressure. The augmented haemic oxygenation thus
brought about leads both to an increase in the number of
red corpuscles as well as of the amount of hsemoglobine con-
tained in each. At first, owing to the general lassitude of
which chlorotics suffer, exercise will have to be of a very
gentle nature. Often, indeed, it will be necessary to begin
with such passive motion as is afforded by driving or by
passive muscular exercise, or the patient may be subjected to
a thorough rubbing and kneading.

In chronic gastritis mechano-therapy, like hydrotherapy, can

218

EXERCISES WITHOUT APPARATUS.

is an indubitable sign of the likewise improved nutritive pro-
cesses which have begun in the organism.

A daily walk over some elevation, which going and coming
would occupy from half an hour to an hour, would in all prob-
ability be quite sufficient for the achievement of our purpose.
For delicate persons a well-kept, even road should be selected.

Since various obstacles may arise to this form of exercise —
as inclement weather, the tendency on the part of the patient
to overdo the matter, and thus incur fatigue, etc. — and as it is
desirable for the patient to be constantly under the care and
guidance of a physician, the following forms of exercise may
be pursued in the house instead.

For patients of phthisical inclination, or for those with nar-
row chests, and of poor development generally, the following
exercises are suited.

I. Exercises without Apparatus.

1. Shoulder raising, with and without dumbbells. (Fig. 60.)

2. Arm raising sideways, with and without dumbbells.
(Fig. 61.)

3. Arm raising forward, with and without dumbbells.

Fig. 60 . Fig. 61 .

EXERCISES WITHOUT APPARATUS.

219

Fig. 62. Fig. 68.

4. Arm circling. (Fig. 62.)

5. Touching elbows behind. (Fig. 63.)

Fig. 64. 65.

6. Clasping hands behind. (Fig. 64.) ^

7. Shoulder hitting forward, first without, then with, dumb-
bells. (Fig. 65.)

220

EXERCISES WITHOUT APPARATUS.

Pig. 66. Fig. 67.

8. Shoulder hitting sideways, first without, then with, dumb-
bells. (Fig. 66.)

9. Shoulder hitting upward and downward. (Fig. 67.)

10. Swimming motion, both with and without dumbbells.

Pig. 68. Pig. 69.

11. Sawing motion (Fig. 68), with and without dumbbells.

222

EXERCISES WITH APPARATUS.

II. Exercises with Apparatus.

a. On the Parallel Pars,

Fia. 74.

2. Stiff' elbow rest. (Fig. 75.)

224

KBITBASTFENIA.

Since horizontal and parallel bars are forms of apparatus
easily put up in any room, every physician should make him-
self familiar with the exercises to be performed upon them.
There is hardly a busy practitioner who has not frequently to
treat a young person for incipient phthisis. A suitable climate
and plenty of nourishing food will be prescribed, but how
seldom is a systematic development of the chest recommended.
Yet I venture to say that the use of methodic gymnastics, such
as I have laid down, will be of more use than any of the most
highly prized medicaments.

The physician should, if possible, himself direct the daily
round of exercises, for they gain in this way an importance,
both in the eyes of the patient himself and of those about
him, which they could not otherwise obtain. Fifteen to
twenty minutes a day is all the time the physician need give.

Patients should be urged to repeat daily the exercises for
themselves. Many young men and women fall an early prey
to consumption largely because rest and quiet have been
preached, instead of urging them so to strengthen their
systems by active exercise as to successfully combat the
disease. When once the disease has n.ade advances, if the
lungs are already infiltrated or softened, or if haemoptysis and
fever have occurred, then, to be sure, it is too late to attempt
to do anything by gymnastics. Rest and nursing are then the
only means of prolonging for a brief season the constantly de-
clining powers.

In the mechanical treatment of neurasthenia and its allied
aftections, hysteria, hypochondria, and some of the milder
psychopathies, we seek to attain a threefold end. First, to
regenerate the mass of blood as a whole ; secondly, to combat
individual symptoms ; and thirdly, to favorably infiuence the
mental state. Beard, w’^ho claims for neurasthenia that it is a
new, and especially American disease, considers mechano-
therapy as not only essential in its treatment, but absolutely
indispensable for those cases which it seems advisable to
confine to bed.

This I am quite willing to admit, inasmuch as this class of
invalids seem to be benefited by any new form of treatment,
no one form in particular enjoying a preeminence. Change

230

NEURASTHENIA.

of scene and mode of life are often sufficient, consequently
where electricity or hydrotherapy has done good, still better
results would most likely be attained by mechanical treatment,
especially in cases where either special symptoms, or the condi-
tion in general seem to indicate it.

Amid all the numerous morbid manifestations accompanying
neurasthenia, hyperjesthesia and muscular weakness are prob-
ably the most prominent, so that Arndt* has declared the
nature of the disease to consist in imreased irrikdnlity^ with
rapid tendency to fatigue^ especially of the muscular system..

In neurasthenia, as in muscular rheumatism, all the morbid
processes occurring in the muscles are more rapidly influenced
by mechano-therapy than by either hydro- or electro-therapy.
Of all symptoms the various hypersesthesias most frequently
engage the physician’s attention. These are generally regarded
by the friends as founded either on exaggeration or upon
affectation. Patients complain of muscular pains especially
in the extremities and back, and of pains along the spinal
column, the latter being, indeed, considered quite charac-
teristic of the disease spinal irritation”).

Besides these, neurasthenics suffer from the greatest variety
of symptoms referable to the brain, as headache and a feeling
of weight or constriction in the head, eye-ache, photopsia,
scotoma, roaring and ringing in the ears, hypersensitiveness
to odors, and other similar idiosyncrasies. Or there may be
liability to sudden changes of temper, or to depression and
sadness, or dizziness or insomnia may exist. Indeed the large
number of various feelings of apprehension experienced in
neurasthenia has been the occasion for the manufacture, by
various authors, of any number of ‘‘phobias.” The restless-
ness so often seen in these patients is caused by the pains
occurring in various muscle groups.

From the very fact that neurasthenia depends in a great
measure upon an inborn tendenej^ and may consequently be
regarded as an anomaly of constitution, the uselessness of
drugs becomes at once evident, and any therapeutic measures,
whether they consist in electricity, hydrotherapy, change of
air, or mechano-therapy, will only then be effectual when they

1 Arndt: Beal-Encyclopiidio der g^mmten Heilkunde. Bd. ix. Wien und Leipzig, 1861.

briug about a radical change in the patient’s whole mode ot
life. The treatment of these cases, consequently, so long as
they remain within the influences of the family circle where
apparently trivial causes are constantly influencing the patient,
is often attended with many obstacles. Even change of scene
will be useless if the deleterious home influence accompany
the patient. They recover soonest in the busy life of a hydro-
pathic establishment, where all necessary appliaiices are at
hand, and where they can constantly consult a doctor on all
their various aches and pains. In the management of the
establishment they soon take an active interest, and the daily
exercises performed in company with others afford a pleasant
entertainment, as well as healthy stimulus to the mind.

The active motions to be used consist of exercises with and
without dumbbells and with the wand, on the parallel and
horizontal bars, on the inclined and horizontal ladder, on the
spring-board, and, in short, in exercises of every kind suited
to the strength and dexterity of the patient.

The putting on and off* of the gymnasium suit twice a day
is in itself often enough to pat a neurasthenic patient in a
good humor with himseJf, for be feels as though something
were really being done for him, and as though somebody had
an interest in his getting well. It is a very wrong principle to
go on, to treat all complaints of these patients as due to imagi-
nation or affectation. To them all the unpleasant feelings they
experience seem perfectly real.

General massage of the whole body, including stroking,
kneading, muscle-hacking, etc., will be found more effectual
in banishing the various anaesthesias and hyperaesthesias than
electricity, while passive motions of all the large joints —
flexion, extension, and rotation — cause a stretching of the
nerves contained within the muscles, which reacts most favor-
ably upon the mental state.

In contrast to a neuralgic patient, a neurasthenic longs for
the hour of treatment, and I have been received with tears
and reproaches, by such patients, for coming an hour later
than I had promised.

In an establishment, treatment should be undertaken twice
a day. It is not necessary that the manipulator should, for

232

NEURASTHENIA.

these cases, be a physician, though it is well for the attending
physician to superintend the exercises from time to time, if
only for the patient’s sake, for they require both attention and
sympathy.

Case IX. — Mr. C. von M., a Eussian, aged thirty-eight, was
sent to me to Aussee from Meran, by Drs. Tappeiner and
Hausmann, in order that the climate of this high valley might
cure a condition which had caused him for some years to
wander from one health resort to another.

Examination proved negative regarding the existence of any
organic pathological condition, and yet the patient felt ill and
miserable to the last degree. He could not walk ten minutes
without fatigue. Anorexia was complete, and the bowels
moved only on taking cathartics. This bodily condition had
reacted most deleteriously upon the mind, for he was in a
state bordering upon melancholy, his wife affirming she had
not seen him cheerful for years, and that he had, indeed, quite
forgotten how to laugh.

Tenderness along the spinal column, muscles flabby and
small, complexion sallow and anaemic — all went to complete a
picture of a typical case of neurasthenia.

A four weeks course of daily repeated active and passive
exercises, lasting thirty to forty-tive minutes, completely
changed this apathetic, morose, taciturn, and disagreeable
individual. He had now a tremendous appetite and a daily
passage from the bowels, could walk for four hours without
fatigue, and in place of his former melancholy disposition, a
decidedly jovial nature appeared.

These remarks upon neurasthenia are equally applicable to
hysteria, hypochondria, and those , mild psychopathies con-
nected with them, which Arndt and others regard as simply
more marked grades of neurasthenia. If, for instance, to un-
naturally rapid fatigue of the muscles, there is added a spas-
modic condition, then the neurasthenic becomes converted into
an hysterical or even epileptic state. Or if, instead of fatigue
alone we have, following exercise, a period of mental excite-
ment, either with or without feelings of oppression and dread,

HTSTERIA.

238

then we have to do with a case of hypochondria or melan-
cholia, or with an instance of “ forced ideas ’’ such as often
precede some forms of insanity.

According to Arndt, a separation of neurasthenia from
hysteria and hypochondria is quite impossible unless we set up
all sorts of artificial distinctions. He considers the numer-
ous terms of dififerent authors — such as spinal neurosis, spas-
mophilia, spinal weakness or irritability, nervosism, erethism,
the nevralgie ghiirate qui simule des maladies graves des centres
nerveux of Valleix, the nevropatJde proteiforme^ the surexcitation
nerveuse of other French writers — as all but different names for
one and the same condition. All writers agree, however, on
the impossibility of permanently curing this condition, and
above all, that no medicaments exist capable of permanently
allaying the irritability of the hypersesthetic nerves.

Gerhard^ and other authors assure us that convalescence
may begin quite suddenly at any time, no matter how alarming
the symptoms appear to be. Nevertheless, these patients
require careful medical supervision, their mode of life must be
regulated, they must have plenty of sleep and fresh air, and
be furnished with some pleasant mental occupation — as some
form of literary entertainment, or music — as well as bodily
exercise. The latter is best obtained by a daily course of
carefully systematized exercise, this being more efiScacious
than electricity, if only for the reason that the patient’s mind
is thus pleasantly occupied for a couple of hours. The hydro-
pathic establishments have so fully recognized the importance
of mechano-therapy that they have, with few exceptions,
embraced such a course within their programme. The moral
influence which it is within the power of the physician to
display in these cases is so great that it has given rise to the
expression that “ the physician, not the physic, cures.”

The good result recently claimed for hypnotism in these
cases is but fresh proof of the power of psychic influences, and
in applying general faradization, massage, and all other thera-
peutic measures it is really this influence which comes into
play. The well-known case of Dr. IsraeP is a very instructive

1 Gerhard: TJeber einige Angioneurosen. Volkmann’s kiln. Vortriige. Leipzig, 1881.
* James Israel: Berliner klin. Wochenschr., 1880, No. 17.

234

DIABETES MELLITUS.

one in this connection. An hysterical patient suffered greatly
from ovarian neuralgia accompanied by constant vomiting.
All other means having failed, castration was proposed. The
patient was chloroformed and a simple incision was made in
the skin only, the wound was then dressed daily with much
show of care. The patient, who believed she had been cas-
trated, was by this means completely cured of a neuralgia
which had tortured her for six years.

Rheinstiidter,^ in his interesting work on female nervous-
ness, insists on the importance of placing young girls inclined
to be ‘‘ nervous ’’ under the influence of some good practical
housewife, who will dispel their fantastic ideas, as well as of
encouraging them in gymnastics, swimming, and all sorts of
bodily exercise.

Diabetes Mellitus.

Of late years this disease has been included within the
range of median o-therapy. The statistics of those who have
had most occasion to study it (Seegen, Trousseau, Fleckles,
Zimmer, etc.) show that a large percentage of cases occur in
corpulent individuals belonging to the richer classes of society,
and that an inactive mode of life, affording but little bodily
exercise, combined with excesses in diet are favorable predis-
posing causes. Of 218 cases, Cantani found that 109 were
made up of persons retired from business, of priests and of
lawyers.

Among the commonest symptoms are muscular weakness
and its accompanying fatigue, Avhich Senator^ refers to the in-
suflficient nourishment which the saccharine blood afibrds the
muscles. Spasms and cramps, especially in the legs, are also
of frequent occurrence.

Cantani holds diabetes to be due to a metabolic anomaly, in
which both the sugar ingested, and that formed in the body
from albumins, is not destroyed as is normally the ease, and
hence reappears in the urine. All physiologists agree on the
muscles being the principal seat of metabolism, and Zimmer*

^ Bbeinstiidter : Ueber weibliche Nervositat. Volkmann’s klin. Vortrage. Leipzig, 1880.

2 Senator : Article on Diabetes Mellitus in Ziemssen’s OyclopoRdia.

s Zimmer ; Die Muskeln eine Quelie, Muskelarbeit ein Heilmittel bei Diabetes. Carlsbad, 1880.

DIABETES MELLITUS.

285

goes so far as to ascribe to the muscles, as well as to the liver,
a. causative influence in the production of diabetes, especially
in the more severe cases. He reasons as follows: Liver and
muscle both contain glycogen, a ferment, and water — the three
elements necessary for the formation of sugar. The proportion
of glycogen and ferment are relatively constant, while that of
water is variable. If the amount of water be permanently
increased, a continuous formation of sugar in these organs
occurs, and diabetes results.

According to Senator, an increase in the amount of sugar in
the blood derived from the muscles can only be accounted for
by considering the mutual relations existing between the liver
and the muscular system, as follows: Where the diabetes is of
hepatic origin the liver will be in a state of constant hyper-
semia. Active exercise, however, causes a diminution of the
amount of blood in all internal organs through determination
to the muscles, and the oxidative processes taking place in the
latter result in the combustion of much of the sugar contained
in the blood. Thus in diabetics who indulge in little or no
exercise accumulation of sugar necessarily occurs.

Zimmer claims as another advantage following physical ex-
ercise, that well-developed muscles are capable, even when in
a state of rest, of disposing of much more sugar than feeble
muscles would be, and his observations undoubtedly confirm
this assertion, for on a day of rest following several days of
exercise, much less sugar w^as found than formerly, when no
exercise at all had been taken.

Long ago Bouchardat affirmed that the sugar diminished,
and might even disappear, from the urine after muscular exer-
cise, and Zimmer is quite convinced that persistent exercise,
involving all the large muscle groups, is capable of entirely
curing hepatogenous diabetes in many cases, and much im-
proving the condition in others.

As only about one case in twenty of hepatogenous diabetes
is a so-called grave one — L e., where the glycogen-forming
function of the muscles is affected — it follows that the treat-
ment by exercise becomes all the more important. Zimmer,
however, does not omit to warn his readers of being too san-
guine of success; all cases not being alike amenable to treat-

236 CEBEBRAL CONGESTION, HEMORRHOIDS, BTC.

ment, because not all muscles are capable of being developed
and strengthened. In old, run-down, and anseinic individuals
this toning up is naturally more difficult to accomplish than in
the young and vigorous. Heart and lung diseases too, are ob-
stacles, inasmuch as any very energetic exercise cannot be in-
dulged in at all.

Zimmer cites cases in which exercise, in the beginning,
either remained without effect, or even increased the glyco-
suria. In these cases some muscular insufficiency must exist,
the cause of which it is not always easy to determine. Often,
it will be found to depend on an excess of fat in the muscular
tissue itself. He mentions the case of a patient weighing 262
pounds, in whom exercise at first caused an increase of the
sugar voided, ending, however, in effecting a diminution.

Occasionally it will be found best to defer the use of exercise,
or even to abandon its use altogether, or to precede it, or sub-
stitute it entirely by mechanical manipulation.

Zimmer mentions the good results of exercise employed in
the grave form of the disease, and thinks its effects, on the
whole, more lasting than those obtained by diet, as prescribed
by Hollo.

As the best effects will ensue when the greatest number of
muscles are brought into play, it will be necessary to select
such forms of gymnastics as will call into action, equally, all
the great muscle-groups. All the various kinds of apparatus
mentioned in former chapters should be employed in turn.
Hiding and fencing are also highly to be recommended.

GROUP IV. MECHANO-THERAPY IN CEREBRAL CONGESTION,
HEMORRHOIDS, AND PULMONARY EMPHYSEMA.

The capacity possessed by the muscles of containing con-
siderable quantities of blood when in a state of functional
activity, may be utilized to relieve the congestion of internal
organs. It is notorious that those engaged in sedentary occu-
pations are liable both to cerebral congestions and to hemor-
rhoids ; conditions which disappear when plenty of daily exer-
cise is indulged in.

Persistent congestion of an organ finally causes venous dila-

PULMONABY EMPHYSEMA.

237

tation with atony of the muscular coat of the walls of the
vessels; a pathological condition which, once developed, no
exercise or any other therapeutic measure is capable of re-
moving.

Pulmonary emphysema can never result from lack of bodily
exercise alone (though Rokitansky once assumed it could), but
it arises from all such conditions which call for forced expira-
tion. Hence difficulty attending defecation may act as a cause.
It is certain that where emphysema preexists, constipation,
with its consequent straining at stool, greatly aggravates the
condition. And as muscular inactivity is a direct cause of
intestinal inactivity, it follows that emphysematous patients
should take daily exercise, either in the form of walks or as
well-regulated gymnastics — care being taken to observe a
proper moderation, for excess is worse than no exercise at all,
since it tends to overtax the lungs which are already in a state
of textural degeneration and functionally weakened. Only
just enough muscular exercise, therefore, should be employed
as will suffice to divert the excess of blood from the over-
burdened lungs to the muscles.

The pneumatic treatment of emphysema, which consists in
making the patie^nt expire in rarefied air, is in effect purely
mechanical. The impure residual air is pumped out hy this
raeans,^ diminishing the distention of the alveoli, which are
then, at the next inspiration, filled with fresh air.

At the same time capillary circulation is stimulated and the
nutrition of the parenchyma improved. By frequent repeti-
tion of this process it may, perhaps, be possible to cause a res-
titution of those portions of the lung which, though abnormally
stretched, have not yet begun to degenerate.

Gerhardt recommends as another mechanical mode of treat-
ment, alternate rhythmic compression of thorax and abdomen.

While in emphysema active exercise will always have to be
kept within quite limited bounds, much benefit may, on the
other hand, be derived from general massage. Patients with
cerebral congestion or hemorrhoids will require thorough gym-
nastics of the whole body. Let them begin with exercises for

1 No mechanical means suffice to remove the residual air, though, no doubt, by the above method
much of the reserve air can be removed. — T uams.

288

INDIGESTION AND CONSTIPATION.

the head and neck, following next with those for the arras,
trunk, and legs. The latter patients are particularly benefited
also by the passive moveraents to be described under the next
group.

GEOUP V. MECHANO-THEKAPY IN CHRONIC DIGESTIVE
DERANGEMENTS AND CONSTIPATION.

These two conditions are almost invariably associated, for
if either has existed any length of time, the other is sure to
follow. It should be understood that only such derangements
are considered here as arise from so-called ‘‘abdominal ple-
thora.”

Since digestion, absorption, and defecation are all dependent
upon nervous influences (coming from the sympathetic, vagus,
spinal ganglia, vaso-motor nerves, etc.) which govern the com-
plicated digestive process, it is readily conceivable how even
purely psychic influences may aflect them.

Digestion, and the subsequent propulsion of the food along
the intestinal tract, depend, however, not upon the intrinsic
intestinal muscles alone, but upon the varying calibre of the
intestinal bloodvessels, and upon the blood pressure as well.
Consequently the heart becomes an important determining
factor, for when the blood pressure in the intestinal vessels is
low, congestion of the portal system, with all its subsequent
train of evils, follows. The intestinal circulation, as well as
the propulsion of the chyle, is also largely dependent upon the
vigor of the respiratory act. Shallow, superficial breathing
calls forth but slight diaphragmatic activity, and as the action
of the abdominal muscles is reciprocally proportionate to that
of the diaphragm and intercostals, it follows that diminished
respiratory energy lessens abdominal muscular action. The
harmful eflects of this inactivity are then superadded to those
which have already arisen from diminished flow through the
intestinal vessels. The intimate connection which exists
between bodily activity on the one hand, and digestion and
defecation on the other, is thus readily explained.

Besides this physiological relationship between bodily ac-
tivity on the one hand, and cardiac and pulmonary on the

INDIGESTION AND CONSTIPATION.

239

other, there is, according to Johannes Miiller, still another bond
of union. He was of opinion, namely, that activity of the
voluntary muscles called forth, in accordance with the law of
coordinated movements, contraction of the involuntary mus-
cular fibres as well, and among these, those of the intestinal
tract.

Virchow refers portal congestion to two prime causes.
First, to disturbed innervation of the muscular coat of the
arteries and veins, leading to loss of tone, the elastic fibres
gaining the preponderance. In consequence, the vessels
become dilated and relaxed, the blood flowing sluggishly,
just as any stream flows more slowly when turned into a
broader bed. Secondly, to venous congestion from diminished
cardiac power. All kinds of digestive diflSculties naturally
develop from these circulatory disturbances. The distended
portal venous radicles lose, to a great extent, their absorptive
capabilities, and the lymphatics being unable to meet the in-
creased demands upon them, it follows, as a matter of course,
that the food mass remains in the stomach and intestines an
abnormal length of time. In consequence of this, all sorts of
fermentative changes go on in the mass, the products of which,
being absorbed Jnto the blood, give rise to a general distur-
bance of nutrition. The thus altered contents of the alimen-
tary canal, by irritation of the mucous membrane cause reflexly,
also, all kinds of nervous symptoms, such as nausea and vomit-
ing, colic, and cramps, and as the result of chemical changes,
eructations, heart-burn, and sour and bitter tastes. The coex-
isting constipation too, by barring the way for the escape of
those gases which are always developed during digestion, gives
rise to flatulency and “ bloated feeling.”

When these conditions have lasted for some time, emaciation,
lassitude, and mental depression set in, the latter sometimes
ending in melancholia and hypochondria.

Virchow thinks it not impossible that even ulcer of the
stomach and nutmeg liver may result from persistent con-
gestion. Certainly, the most frequent causes of these diseases,
are sedentary occupations, involving lack of use of the volun-
tary muscles — especially the respiratory and abdominal.

That the cause of dyspepsia often remains undiscovered

240 •

INDIGESTION AND CONSTIPATION.

lies in the fact that it may take years before the disease really
becomes very troublesome. Patients often will tell you : “ I
have been accustomed to sit a great deal for years, but I have
never been troubled with indigestion until lately.”

Occasionally the original source of these troubles is to be
sought in some previous disease involving the intestines — as
dysentery or typhoid fever — or in cases tending to lower
vitality generally, as sexual or alcoholic excesses, immoderate
mental work, great emotion, etc.

It must be borne in mind, however, that individuals — espe-
cially young ones — exist who are always, from no apparent
cause, most obstinately constipated.

When the fecal masses collect until they become so large
and dense that the muscles of the intestines are no longer able
to propel them along the canal, it becomes the object of
mechano-therapy to restore the lost, or at least diminished
energy of the muscular coat of the gastric and intestinal portal
vessels. This may be accomplished in several ways.

First, vigorous general exercise of the whole body. This
stimulates the heart, increases the general blood pressure in
all the vessels, and causes an increase in strength and tone in
the vascular muscular coat, which like all muscles follows the
law that muscular power grows in proportion to the demands
made upon it. According to Du Bois-Raymond ustriped
muscle fibres become stronger by exercise, and pathological
experience with the bladder, etc., confirms this. Rosenthal’s
supposition that immunity conferred against catching cold by
the use of cold baths depends on exercise of the unstriped
muscle fibres of the skin and its vessels rests consequently
upon, at least a certain empirical foundation, for Du Bois-
Raymond says : “ Cold washing and bathing are gymnastics
for the cutaneous muscles.”

Secondly : Special exercises for the abdominal and thoracic
muscles.

By these the organs contained in the respective cavities can
be roused from their habitual torpor and be made to recive a
salutary shaking up. Deep vigorous respirations increase the
activity of diaphragm and abdomen, and by thus causing
rhythmic alternations of intra-abdominal pressure, lead to in-

EXERCISES WITHOUT APPARATUS.

241

creased rapidity of circulation throughout the whole portal
system. In consequence, the muscular power of the portal
vessels is increased and the blood pressure raised. The nor-
mal conditions of pressure being thus reestablished propulsion
of chyle and feces is resumed, the muscles of the intestines
gradually regain their lost powers and, finally, all the functions
are again restored to normal.

The following exercises are recommended :

A. Exercises without Apparatus.

1. Body-bending — forward (Fig. 90), backward (Fig. 91),
right, left — aid being given by the assistant when necessary.

Fig. 90 . Fig 91 .

All the exercises are to be repeated ten to twenty times,
according to the number of different ones employed each
time.

2. Body-circling — is a combination of the four above. The
assistant should stand in front of the patient, guiding the
circling motion of the trunk — which describes a cone whose
apex is at the sacrum. The feet should be close together and
the hands on the hips (Fig. 92).

8. The knee-lift. The body being bent slightly forward, the
knees are to be sharply raised till they touch the chest (ten
times with each). Fig. 93.

242 INDIGESTION AND CONSTIPATION.

4. Horizontal arm motion (Fig. 94) — backward and forward.
The body being bent backward when the arms are brought

Fig. 92. - Fig. 93.

forward, and forward as the arms go back; thus bringing the
abdomen into action. It should be done both with and with-
out dumbbells.

Fig. 94. Fig.' 95.

EXERCISES WITHOUT APPARATUS.

243

5. Arm motion from side to side (Fig. 95) — the body being
bent slightly forward and participating in the movements
(with and without dumbbells).

Fig. 96.

..-.y ' % !

/ ] M

6. Hewing (Fig. 96). The patient, standing with legs apart
and toes turned out, raises his extended arms above his head

Fig. 98.

244

INDIGESTION AND CONSTIPATION.

and then bends the whole body forward and downward as
though splitting a piece of wood at his feet with an axe. The
hand should pass between the legs (with and without dumb-
bells).

7. Sawing (Fig. 97). The body being bent well forward,
each arm alternately makes movements as though using a saw.

8. Step-changing — with alternate rotation of the trunk.
This movement, which is difficult to describe, will, however,
at once become clear on referring to the figure (Fig. 98).

9. The lunge — with backward and forward movement of
the trunk (Fig. 99). The patient steps with one leg as far
forward as possible, bending the knee, the other leg remaining
extended. The body is then bent forward as far as possible,
and kept so for twenty seconds, when it is thrown backward,
the bent leg at the same time being extended, and the straight
being bent. This is to be repeated five times before changing
sides.

Fig. 99.

Fig. 100

10. Squatting (Fig. 100). Hands on hips, heels together,
toes out, then sudden squatting motion, remaining in this
position about ten seconds, when the erect position should be
recovered with a spring. This movement must be performed
quickly.

246

INDIGESTION AND CONSTIPATION.

B. Exercises with Apparatus.

I assume that treatment is to be pursued at home, and con-
fine myself, therefore, to mentioning such simple apparatus as
can readily be erected in any private dwelling.

For extension of the body a detachable horizontal bar can
be put up between the jambs of a door, or hanging rings
may be suspended from a couple of stout hooks let into a

Fig. 105.

Fig. lOG.

beam in the ceiling.^ The rings have the advantage over the
bar, that they can be used for exercises for which the latter is
not suitable. They should have straps and buckles by which
they can be made higher or lower.

^ As all dealers in sporting goods keep this kind of apparatus, a detailed description seems super-
fluous for American readers. — Trans.

EXEBCISES WITH APPABATUS.

247

1. The hanging leg-lift (Fig. 105). The rings should be
just low enough to be grasped on tip-toe. Then, hanging by
the arms the extended legs are to be raised to as nearly a
horizontal position as strength will allow, ^ and then allowed
to sink again. This must be repeated ten times.

2. The hanging leg-kick (Fig. 106). The patient hanging
from the rings as above, draws both knees to the chest and
then gives a sudden downward kick, extending the thighs at
the hips. To be repeated ten times, with a rest in between.

Fia. 107.

3. The hanging leg-circling (Fig. 107) — is analogous to body-
circling. While hanging the legs are circled first to the right
and then to the left — each ten times. This movement is some-

1 Simple as this exorcise seems, it requires great strength — such as few possess— to raise the
extended legs until they form a right angle with the body, and to h«ep them so. — T banb.

248

INDIGESTION AND CONSTIPATION.

what difficult, as the trunk easily participates in it. This,
however, should be prevented.

4. The funnel (Fig. 108). The rings are lowered as far as
the breast, the patient then grasps them, extends the arms, so

Fig. 108 .

as to lower the body backward, keeping his feet at the same
time just beneath the rings. Then by flexion of alternate arms
the body may be so set in motion as to describe a funnel or
cone, of which the feet are the apex. This should be per-
formed first to the right and then to the left.

Passive Movements.

While many diflterent kinds of passive exercises are com-
monly performed in movement-cure establishments, the fol-
lowing will amply suffice for all purposes.

1. Rotation of hips. (Fig. 109.) The patient steadies him-
self by the bar with both hands, while the manipulator, who
stands behind, firmly grasping each hip, rapidly turns the
pelvis from side to side. The patient must, of course, relax
the pelvic muscles. This should be done twenty times, and
then repeated after a short rest.

PASSIVE MOVEMENTS.

249

Fio. 109.

2. Rotation of the thigh. The patient lies flat on the bench,
in such a manner as to allow the lower extremities, from the
trochanters down, to project beyond the end. The attendant
seizing each extended leg by the ankle, circles it round and
round, first ten times to the right, then as many times to the
left. (Fig. 110.)

Fui. no.

260

INDIGESTION AND CONSTIPATION.

3. The knee-chest flexion. The patient lying as before, the
attendant seizes both heels and forcibly flexes the thighs upon
the body, until the knees touch the chest. The thighs are
then forcibly extended again. (Fig. 111.)

Fig. 111 .

Chronic constipation offers the most signal successes to
mechano-therapy, for it is possible to make direct mechanical
pressure upon the coeliac and hypogastric plexuses and through
these to reflexly excite peristalsis; furthermore, the vasomotor
nerves and the intestinal muscular fibres are directly stimu-
lated by the pinching and squeezing to which they can be
subjected.

The coeliac plexus and its ganglia, since they lie upon the
anterior aspect of the aorta, may be easily reached by pressing
deeply midway between the xiphoid process of the sternum
and the umbilicus. The hypogastric ganglia and plexus are
reached by making pressure midway between the umbilicus
and symphysis pubis. The finger tips should be used in both
instances, the patient half lying, half sitting upon the bench,
with knees elevated to relax the abdominal muscles. (Fig.
112.) I prefer to manipulate, not only the areas just men-
tioned, but the whole abdomen as well, first transversely, then
longitudinally. After this procedure — which should be carried
out with a peculiar rotatory thrusting movement — has been
gone through twenty or thirty times, I grasp the upper por-

PASSIVE MOVEMENTS.

251

^ tions of the ascending and descending colons between thumb
and ^fingers of either hand and subject them to a vigorous

Fig. 112.

Fig. lU.

252

INDIGESTION AND CONSTIPATION.

pinching and kneading. Finally, I make firm pressure in
the inguinal regions in order to reach the caput coli and
csecum on the one side, and the rectum on the other.

For strengthening the abdominal muscles there is nothing
better than the apparatus shown in Fig. 113, resistance being
increased from time to time by weights.

General Observations.

It is perhaps hardly necessary to say that mechanical treat-
ment must always be supplemented by proper diet.

Every now and then we come across young persons — gener-
ally girls — who, while otherwise healthy, suffer from obstinate
constipation. The fecal masses are so largo that their passage
through the intestinal canal tries the elasticity of the muscular
fibres to their utmost, the rectum, especially, being in a con-
stant state of distention.

I have repeatedly seen in these cases — where formerly a
movement could only be obtained by drugs — a few weeks of
mechanical treatment bring about defecation immediately
after the manipulations. The duration of treatment will often
have to last from four to twelve weeks, hence it would not be
justifiable to give up a case if after, say, six weeks no cure
had been obtained. On the other hand, there are patients —
happily rare exceptions — in whom a most careful three months’
course produces no results.

A recital of cases would be of no interest, since they are all
as much alike as two peas, and I only give the one below
simply to show that in some cases mechano-therapy may
prove a last resource when all means have failed.

Case X. — H. von B., aged fifty-four, had suffered for years
from constipation, so that a movement was not possible un-
assisted by drugs.

After trying all sorts of remedies, he finally resorted to a
dietetic cure at Wiel’s establishment in Zurich, but without
success. He was then treated by me for four weeks, with
such good results that he now enjoys a daily natural movement
without the use of medicines.

CHOEEA.

253

GROUP VI. MECHANO.THERAPY OF CHOREA AND
WRITER’S CRAMP.

However familiar the symptoms of these two affections may
be to us, their pathological anatomy is still involved in ob-
scurity.

Chorea.

Ziemssen^ agrees with Charcot in placing the seat of this
disease in the cerebral hemispheres, and more especially in the
basal ganglia, while others (Bert, Onimus, Chauveau, etc.) refer
it to the cord, and almost as much diversity of opinion exists
about the nature of the excitant as there is regarding its loca-
tion. Some look upon embolism in the corpus striatum or
thalamus as the cause, while the cases following sudden emo-
tion — as fright — have been referred to disturbances of cerebral
nutrition resulting from vasomotor disturbances secondary to
the psychic shock.

It has heretofore been customary to regard general toning
up of the organism by fresh air and proper food, induction
of sound sleep, and careful and tender physit*al and moral
supervision as merely secondary to all other forms of treat-
ment. Let us, however, look a little more closely into
mechanical treatment.

Some regard it onl}^ as adjuvant, while others are inclined
to give to it a major irnportance. Thus, Ziemssen recom-
mends it only during the decline of the disease, using it to
stimulate the will by fixing the attention upon the exercises to
be executed. He assumes, as a matter of course, that no one
would think of treating a chorea, symptomatic of cerebral or
spinal disease, by gymnastics. Yet the purely mechanical
treatment of chorea is by no means a new idea.

In 1847, trials had already been made in Paris in the Hopital
des Enfants Malades, and up to July 22, 1851, ninety-five cases
which had resisted all other forms of treatment, were recorded
as cured by methodic exercise. In that year, too. Dr. Blache
addressed an assembly composed of the directors of the As-

1 ZiemBsen’a article on Chorea, iu Zieraseen’e Cyclopredia

254 CHOREA AND WRITER'S CRAMP.

sistance Publique, as well as many prominent physicians, upon
the results of this new method, executed under his orders by
the then celerated masseur Napoleon Laisne. Only a short
time before. Dr. See had published an article, which received
a prize from the Academie des Sciences, in which he placed
gymnastics in the very front rank of therapeutic measures.
Blache closed his report by saying that in four years not one
of the choreic children treated by gymnastics had suflFered a
relapse.

Laisne, who was not a physician, but Professor of Gym-
nastics at the College Louis le Grand, in his work on the sub-
ject,^ cites a large number of valuable observations made by
himself in the treatment of chorea, and also describes his own
methods.

It is difficult, he says, to give at the outset a prognosis re-
garding duration of treatment, for grave cases often get well
quickly, while seemingly mild forms may run a protracted
course in spite of everything. From his wide experience he
was able to affirm that spoiled, cross, or very nervous children
are more difficult to cure than amiable and sensibly educated
ones. Where the disease was consequent on onanism, he
looked upon it as next to incurable.

In mild cases, simple, rhythmic exercises usually suffice.
Laisne proceeded as follows : He placed the child before him,
steadying it between his knees, then took its hands in his and
performed rhythmic movements with each arm, keeping time
by counting — or better singing — out loud, “one,’' “two,”
“three,” etc.; the child, at the same time, being urged to try
to keep time also with the movements, and not to make
them irregularly. Care must be taken to prevent, in the
beginning, as much as possible, the coincidence of involuntary
movements with rhythmic ones.

When the arms have been exercised, similar movements are
undertaken with the legs.

From time to time a pause for rest is made, during which
the limbs must be held firmly enough to prevent the occur-
rence of involuntary motions. The child is then laid on its

^ N. Laisn^ : Applications de la Gymnastique k la guerison de quelques maladies. Paiis, 1866.

CHOREA.

255

back upon an inclined ladder, the feet being held by an as-
sistant; then, grasping a rung above its head, it holds on in
that position as long as it is able. This is to be repeated
several times, and to be followed by a short rest. Afterward,
the shoulders, back, and legs are rubbed and gently kneaded.
Care must be taken not to demand too much will power of the
child in the beginning, for if the limit be overstepped, not only
instead of soothing effects, do we get increased excitability,
but all the progress made may suddenly be lost. Another
mistake frequently made is to allow the child to walk too
much, nor is it well to let it indulge in the romping games of
other children. Choreic children should not be constantly
reproved for their incoordinate movements. On the contrary,
should they involuntarily let something drop from their hands
they must be kindly soothed and encouraged. Care must be
taken, too, that they do not cut, or bruise, or otherwise injure
themselves.

As improvement progresses and the child becomes able to
perform movements by word of command, new exercises, in
which the child’s own free will alone comes into play, must be
added, such as exercises on the horizontal ladder, and on the
single and parallel bars. As soon as a certain degree of con-
trol has thus been obtained, exercise in company with its com-
panions may be allowed, and thus, gradually, a complete cure
will have been effected without any further special treatment.

All that has been said above pertains to treatment carried
out in children’s hospitals, where there is good discipline, and
where the exercises are under the supervision of a physician.

In private cases treatment is more difficult. We have to
contend with the family, too often lacking in the necessary
appreciation of the situation. The poor child is often treated
impatiently and scolded, no matter how hard it may try —
usages which only contribute, of course, to protract the disease.

The very best of choreic children are usually wilful and
obstinate; still they must not be indulged too much, since that
also only tends to make them worse. It must not be forgotten,
either, that great cleanliness, fresh air, good food, and some
form of quiet div^ersion are indispensable necessities for these
little patients.

266 CHOREA AND WRITER’S CRAMP.

In severe cases the exercises must be undertaken twice daily,
and great care and judgment must be observed in their execu*
tion. At all times careful watching is necessary to prevent
bodily injury. It may even be necessary, in extreme cases, to
fasten the limbs with bandages in bed, to prevent the child
hurting itself either by involuntary blows, or by falling out of
bed.

In the severest form it is best to wait before beginning
gymnastics, until the conditions for treatment beconie more
favorable.

For a child unable to either talk or walk an attendant — some
one familiar with its ways and wants — is indispensable ; because,
as soon as such a child finds that it cannot express itself, it
screams and cries, and the more it wants a thing the louder it
screams. In cases like these it is really a question of divining
the child’s wishes from its looks. Though we may ask the
child all sorts of questions, it only stares at us in reply; but if
the object wanted is not soon found the screaming and ges-
ticulations begin anew. In vain all kinds of playthings are
offered it, and every attempt at quieting it proves useless.

If it is to be fed, it is put upon a chair, one person holding the
body and arms, another holding the head, while a third must
be ready to pop in the food as soon as the mouth is opened.
The same process is gone through lor drinking; a cup is held
to the child’s mouth, and, whenever opportunity offers, enough
for one small swallow is poured in; for these patients are
seldom able to make several consecutive swallowing move-
ments.

Often, indeed, the contents of the mouth will be forcibly
ejected, but we must never be disheartened from making
renewed attempts. All dishes used for the child should be of
tin, so that it may not injure itself by broken glass or crockery.
It will be found best to nourish the child with fluid food, let-
ting it suck it up by a flexible tube, when able to do so.

As the result of numerous observations, Laisne arrived at
the following conclusions :

1. None of the means hitherto employed against chorea can
show such uniform success as gymnastics.

TBBATMENT OF WRITER’S CRAMP. 257

2. The mechanical treatment is applicable to almost all cases,
whereas, the medicinal very frequently is not.

3. The improvement begins as soon as when sulphur baths
are used, while the sedative action usually manifests itself
within a few days.

4. With the arrest of incoordinate movements, the general
health of the child markedly improves, so that not only the
chorea, but the accompanying anaemia is cured as well.

The use of exercises in the beginning might seem to be
rather hazardous, but in reality it is not so. He insists that
only passive motion should be used so long as the patient is
unable to control his muscles.

It may be of interest to mention here, that a young lady,
Mademoiselle Clementine Lebegue, who was herself cured of
chorea by gymnastics, was made professor of gymnastics at the
Hopital Sainte-Eugenie (now Hopital Trousseau), and by her
intelligence, patience, and perseverance, has earned the recog-
nition and esteem of the whole medical staff.

There is indeed no reason why treatment can not be carried
out by any intelligent lay person after receiving instruction from
a physician. The mechanical treatment of chorea exemplifies,
perhaps, better than anything else DuBois-Reymond’s dictum,
that “ muscular exercise is not exercise of the muscles alone,
but exercise of the brain as well.”

Laisne was able to cure cases of chorea whose most promi-
nent symptom had been attacks — occurring often during a
period of years — of spasmodic and most exhausting cough.

In his report Blache^ attaches the highest importance to
passive motion for such children as are too choreic to go
through the regular exercises with the other children. These
motions should even be performed in bed, if necessary.

Treatment of Writer’s Cramp.

Between chorea and writer’s cramp there exists not only an
anatomical and genetic difference, but also a symptomatic one;
in fact, the only similarity between the two lies in the existence

^ Blache : Du traiteroeut de la chor6e par lo gymnastique. Rapport lu I'acad^mie de mddecine !•
10 avril. 1865.

268

CHOREA AND WRITER’S CRAMP.

in both of involuntary, spasmodic muscular contractions. In
chorea, contractions occur independently of time or circum-
stance, or muscle group, or willed action; while in writer^s
cramp and its analogues (piano-player’s, tailor’s, shoemaker’s,
and milker’s cramps), involuntary contractions occur only
when certain acts are attempted, and then only in the muscle
groups involved in this particular action ; and, as a rule, also,
only after the muscles have been working normally for some
time.

Chorea is usually a disorder of the juvenile brain, and is often
associated with other disturbances of central origin both con-
stitutional and hereditary. Writer’s cramp, on the other hand,
is the almost invariable result of over-exertion in adults of the
muscles involved, and arises either from inability of the muscles
to respond to the work required of them, or from some faulty
way of holding the pen.

Various opinions regarding the seat and nature of the lesion
exist, all of which, however, lack positive data. One thing
though, is certain, namely, that the condition included under
the general term of writer’s cramp is dependent on a number
of different pathological conditions. Benedikt has established
three types, differing from one another symptomatically, a
classification to which Erb, in view of our present ignorance
of the true causes, gives his support.

Benedikt distinguishes namely, a spastic, a tremoral, and a
paralytic form. All these three forms have this common
characteristic, that not only in writing, but in any occupation
involving the use of the fingers (as sewing, piano- and violin-
playing, milking, hammering, etc.) the muscles used refuse
after a while to do the required work, and disturbances occur,
manifesting themselves chiefly in the form of fatigue, which
render the occupation either difficult, or wholly impossible.

Benedikt called this form of disturbance a “ coordinative
neurosis of occupation,” because in most cases the coordinat-
ing powers are interfered with.

In the act of writing a large number of rapid but harmoni-
ously regulated movements, occurring both simultaneously
and consecutively, must be performed by the small digital
muscles (lumbricales and interossei), by the flexors and exten-

TREATMENT OF WRITER’S CRAMP. 259

sors of the fingers and especially of the thumb, and by the
muscles of the arm and forearm. As is well known, the asso-
ciation of these numerous movements is only learned in the
course of years and after endless repetition, till finally the act
takes place almost without conscious effort.

According to Erb, it would seem as though the different
volitional impulses necessary for the separate movements of
the fingers and hand are most probably collected in certain
cerebral areas called coordinating centres ; that the tracts
leading from these centres — coordinating tracts — are, however,
to a certain extent at least, independent of the tracts conduct-
ing simple — non-complicated — volitional motor impulses. It
follows, therefore, that the slightest disturbance in any of the
tracts necessarily reacts upon the whole apparatus.

If increased excitability and conductivity exist in certain
tracts — the volitional impulse remaining the while unchanged
— we get a condition of cramp in the involved muscles. If, on
the contrary, resistance be anywhere increased, we get paresis
in the muscles supplied by the affected tracts, while at the
same time spasm of the coordinated muscles will occur as a
result of an increased volition which seeks to be compensa-
tory.

Peripheral lesions of the muscles or nerves may also cause a
disturbance of associated movements, showing itself either in
the paretic or spasmodic form.

The three forms of the disease established by Benedikt cor-
respond to the most prominent group of symptoms in each.

In the spastic form, which is the commonest, tonic or clonic
spasms occur either in single muscles or in groups, after writ-
ing a short time. The thumb and index finger are most fre-
quently affected; either the pen is dropped from the hand on
account of the sudden extension of the fingers, or by the spas-
modic flexion of the thumb and index finger (which at the
same time is generally abducted), it is suddenly lifted from the
table. Occasionally we meet with spasmodic pronation or
supination of the forearm, so that the pen may be either raised
from the paper, or pushed aimlessly back and forth. Still
more rarely are the muscles of the shoulder affected.

The tremoral variety is characterized by a shaking of the

260 CHORBA AND WRITER’S CRAMP.

hand and forearm, rendering the writing irregular and illegu
ible.

In the paralytic form the cramps are replaced by a feeling
of fatigue and weakness amounting practically to paresis.
The hand is as though dead, and is, at the same time, the seat
of painful sensations which radiate to the arm, shoulder, and
even back, after the manner of true neuralgia. At the same
time other acts, of a coarser kind, can usuall}' be perfectly well
performed. In addition to the pains, there is sometimes a
feeling of formication and numbness in certain areas on the
arm and forearm. All the varieties of writer’s cramp are
made worse by any mental emotion or excitement, or by
mental and physical overwork.

The prime cause of the disease is continuous and fatiguing
writing. In rare instances, however, it occurs in those who
write but little. A faulty manner of holding the pen, as well
as pointed or hard pens, certainly contributes to its causation.
Indeed, it has been said that it owes its existence to the intro-
duction of steel pens, but this is undoubtedly an error, for
reports of cases exist, dating back to the time when only ouills
were used.

From al] we know of the nature of the disease we must be
inclined to assume with Erb, that (in typical cases) it depends
upon a disturbance of nutrition of the central nervous system
situated either in the cervical cord, in the peduncles, or in the
cortex.

Nearly all authors agree that the different forms of treat-
ment are alike unsuccessful; certainly a complete cure is a
ranty, though improvement often takes place. In many cases
however, the disease becomes so aggravated in the course of
time that writing has finally to be abandoned altogether. No
matter what the form of treatment— whether by electricity by
hydrotherapy, by gymnastics, by baths, by narcotic or alcoholic
applications, or by mechanical influences— one condition has
always been demanded, namely, that during treatment all
attempts to write should be absolutely abandoned. Recently
Nussbaum, however, has ventured to combat this universally
accepted opinion. In an article* published in 1882 he directs

TBBATMENT OP WBITBR'S OBAMP. 261

his patients to write as much as possible with the instrument
figured and described below, which compels the wearer to use
his muscles in a way diametrically opposite to that he hoa
always practised. He says to his patients: “Write much
with this apparatus, for the more you write, the sooner you
will be cured and be able to hold the pen in the common way
again.’’ The celebrated Munich surgeon is of opinion that

Fig. 114.

Fig. 115.

overexertion of the flexors and adductors — these being the
muscles chiefly used — is the cause of the cramps, and that the
condition may be cured by using the extensors and abductors
instead. To this end he has constructed the apparatus shown
in Fig. 114.^ It consists of a thin, oval band of hard rubber
about two centimetres broad, suitably curved for slipping over

' Made under Nusebaum’s directions by Gebrueder Stiefenhofer in Munich. In ordering, the
natural breadth of the hand should be given.

262

CHOREA AND WRITER’S CRAMP.

the thumb and all the fingers but the little one, which remains
outside. By means of a clamp a penholder can be con-
veniently adjusted. The long diameter of the oval being made
purposely somewhat longer than the breadth occupied by the
fingers over which it is to go, the fingers will have to be
spread apart — the thumb being drawn to the left, the^fingers
to the right — in order to keep it from falling ofi*. Muscles are
thus forced into use which are the exact antagonizers of those
normally used, and at the same time, the act of writing is
transferred from the fingers to the whole hand, and motor
impulses formerly sent to the flexors and adductors now being
transferred to the extensors and abductors.

It is claimed that with this apparatus sufferers from writer’s
cramp are not only enabled to write continuously, but that, by
and by, they can discard it entirely and write with a pen as
before, the increased power which has been given to the
extensors and abductors by exercise suflScing to completely
antagonize any spasmodic action in the flexors and adductors.

As yet, the number of cases treated with this ingenious
contrivance is too small to serve as a basis for any definite
conclusions. It is said that anyone can learn to write well
with his extensors, after only a few hours’ practice. From
personal experience, I should say that this statement may
perhaps hold true for a few. For the sake of experiment, and
not for any therapeutic reasons, I have repeatedly written with
this apparatus for some time together, and I must own that
while my writing may have been distinct, it was certainly
neither beautiful nor fiuent. I do not doubt that after several
weeks’ practice one might perhaps learn to write quite well
and even rapidly with it, but not in a few hours. As might
be expected, the individual strokes are coarse and uncertain.
To keep on the line is a still more diflicult task.

It is natural, however, that a person, formerly unable to
write even his name without getting cramped, would be
highly delighted at being able to finish a couple of pages with
ISTussbaum’s apparatus.

BTussbaum, though considering it alone sufiScient to effect a
cure, holds that massage of the hand and arm as well as baths
and faradization, act as useful adjuvants.

TREATMENT OF WRITER’S CRAMP. 268

He formulates his observations as follows :

1. Every patient, who formerly was unable to even scratch
down his name, let alone write a couple of lines, could, to his
great surprise, write two pages at once and without fatigue,
with the apparatus.

2. No cramps ever occurred while using it.

3. All agreed when using it that those parts of the hand
which were formerly the most painful, felt now even more
comfortable than normal.

4. After using the apparatus diligently for some time a few
patients felt intuitively that they were again able to use the
pen in the old way.

5. In treating this disease it simply stands to reason that the
cramped muscles must be thrown out of use, while their
antagonizers must be strengthened by gymnastics. This end
the apparatus fully accomplishes.

Assuming that the theory of a paresis of the antagonizers is
correct, the end to be attained by mechanical treatment
becomes self-evident. The problem consists in seeking to
strengthen these paretic muscles in every possible way.
Nussbaum^s apparatus fulfils this indication in every respect,
and a better method of calling into action abductors and
extensors it would be hard to conceive.

My own experience with writer’s cramp embraces but two
cases, which I have followed for a number of years with much
interest. A summary of them will be given below.

In the so-called paralytic [paretic] form of the disease in
which there are no cramps, but only a weak, tired feeling in
hand and forearm, every form of exercise may be used to
advantage — pressing, kneading, and hacking the muscles of
the forearm and thumb, and volar aspect of the hand — as well
as employing passive and active movements. To affect* the
interossei and lumbricales, grasp the patient’s hand in both
your own — he being seated opposite — first press the metacarpal
bones up and down and then draw them apart, repeating the
operation many times. Another good passive exercise consists
in grasping either edge of the patient’s hand and depressing
the edges while raising the centre. After repeating this a
number of times the reverse motion should be made. In this

264

CHOREA AND WRITER’S CRAMP.

way these otherwise inaccessible muscles are rubbed against
one another, and their nerves stretched and otherwise sub-
jected to molecular changes. Even electricity is scarcely able
to reach them, situated so deeply and covered by thick skin
and fat, as they are.’

According to Haupt, abduction and adduction are principally
carried out by the interosseous muscles — seven in all — which
are so arranged that each finger has two, the little finger ex-
cepted, which has but one palmar, abduction being performed
in this instance by the abductor digiti minimi.^ When a single
interosseous contracts, the first phalanx to which it belongs
will be drawn toward the same side as the muscle, producing
consequently either abduction or adduction.

Two muscles acting simultaneously upon the same finger
cause flexion, since their tendons are inserted conjointly into
the dorsum of the phalanx, and at the same time into the
tendon of the extensor communis digitorum. By rendering
the extensor communis digitorum tendon tense they allow the
latter to extend the second and third phalanges.

Duchenne explains this seeming paradoxical action by assum-
ing that the interossei cause two diametrically opposite actions
— flexion of the first and extension of the last two phalanges, an
occurrence hitherto unknown in anatomy. Haupt’s demon-
stration, however, entirely clears up this apparent contra-
diction.*

Below will be found an account of the two cases mentioned
as having been under my observation. They present such
differences that one is forced to the belief that wddely differing
pathological conditions must have underlain each, the only
apparent connecting link between them being the common
symptom of disability for the act of writing.

Case XL — Baron d. B., Royal Commissioner of Forests,
forty-four years of age, of excellent constitution, and cheerful

1 With proper electrodes their electric stimulation presents no difficulties — Trans.

* For an excellent account of this subject see a paper On the Anatomy and Physiology of the
Small Muscles of the hand, by Clovis Adam, M.D. Archives of Medicine (Seguin's^ February, 1883.
•~TsAN8.

8 The author certainly labors under a misapprehension regarding Duchenne, who has quite clearly
hown how the interossei cause both flexion and extension. See his “ Fhysiologie desMouvements,’*
Paris, 1867.— Tbakb.

TREATMENT OP WRITER’S CRAMP.

265

temperament. He began to notice the first symptoms of his
trouble in 1872, but attached no importance to them at the
time. During the past five years has experienced a sensation
of heaviness and clumsiness in his hand, especially when
making the shaded downstrokes of letters, like m, w, and /,
which run from right to left and from above downward. In
making the German his hand is involuntarily drawn toward
the left, so that the letter becomes formed like a hook. The
whole hand also has a tendency to rotate toward the radial
side. After writing for from half an hour to an hour, the act
becomes very difficult, irregular, and cramped, until, finally,
the necessary movements become impossible, although the
same movements traced in the air offer no difficulty whatever.

Simultaneously with the above, a painful drawing sensation
occurs in the forearm, the thumb is pressed spasmodically
toward the middle finger, so that in the course of years a
callus has been formed on its third phalanx. After the
‘‘ cramp has begun, single letters can still be formed without
much trouble, but the writing of whole words is impossible
without much pain and exertion ; the writing, too, is tremu-
lous, cramped, and illegible.

When this condition of things begins — which naturally is
very disturbing to the patient’s vocation — he seeks to remedy
it by steadying the right middle finger with that of the other
hand, and in this way prevents the tendency of the former to
move toward the left. For two years past this method has
been the only one allowing of continued writing, and even
with it he gets along but slowly.

The severest pain is located in the wrist-joint itself and just
above, between the ulna and radius. If writing be continued
after the pain has once begun, the latter will extend to the
forearm, arm, and even shoulder, though here — especially in
the supraspinous fossa — it assumes more the sensation of
fatigue. It is rather remarkable, too, that when the barometer
is low the pain is more intense. The relation between pain in
the wrist and the state of the weather is so intimate, indeed,
that the patient is able to tell the approach of bad weather
twelve to eighteen hours before, simply from the degree of pain
and fatigue which writing causes him.

266

CHOREA AND WRITER’S CRAMP.

Every emotion, whether of joy or grief, alike intensifies the
condition. The best time for writing he has found to be in
the morning after having had a good night’s sleep and when
in a quiet frame of mind. Aside, too, from these well-recog-
nized conditions, every day has its good and bad periods, which
occur without discoverable cause.

The baron’s calling obliges him to spend often many days
at a time, from morning till evening, at his desk writing, and
the different phases which his trouble assumes he has observed
to occur as follows :

From 8 to 9 a.m. writing is easiest, then from 9 till 12 m.
the difficulty increases. In spite of a two hour’s rest he
is unable to write any better from 2 to 5 p.m. Then, sud-
denly, and without apparent cause, writing at once becomes
easier, so much so, that he saves all his more important corre-
spondence for this time.

When not at his office the patient amuses himself with
painting and piano playing, and these occupations, though
engaging his right hand constantly, are indulged in for hours
without fatigue. He finds difficulty, however, in painting very
small objects.

If, while writing, he thinks about himself or if obliged to
write very hurriedly, his condition at once becomes worse, and
he begins also to sweat. It should be remarked, too, that on
waking there is a peculiar sensation in his right hand, the
fingers of which feel swollen, and he experiences a certain
clumsiness on trying to pick up small objects. But after
washing and going through a little exercise in his room, these
feelings leave him.

After physical exertion also — an hour’s walk, for instance,
sufficing — writing is more difficult.

After trying all sorts of treatment, the patient came under
my care, August 27, 1882, having received a three months’
furlough to give his hand a complete rest.

I began by massaging, in the manner described above, all
the extensor muscles of the hand, and, at the same time, I
recommended him to learn the zither, my object being to force
abduction through the spreading apart of the fingers which
playing on this instrument necessitates. At that time I was

TREATMENT OP WRITER’S CRAMP.

267

unacquainted with Nussbaum’s apparatus, which accomplishes
the same end, only more perfectly. The thumb muscles, in
playing the zither, are likewise used in a manner directly the
reverse to that employed in writing. The thumb, namely,
plays upon the bass strings — a special “ thimble ’’ being worn
for the purpose — and in order to reach them it has to be widely
separated from the other fingers.

Daily kneading for a month produced no noticeable dif-
ference in the patient’s condition. About this time he noticed
that writing was rendered far easier by grasping with the left
hand the right arm just above the condyles.

Finding that mechano-therapy was without eftect, I tried
hypodermic injections of strychnia, as has been recommended
in this disease. I injected every third day half a syringeful
of a solution of 0.1 strychnine to 20 water, the first injection
taking place on October 30th. The very same day the patient
noticed he could write much easier, and that there was no
tremor. To be sure, he had played a good deal that day on
purpose to tire the muscles of the arm.

Nov. 3. The second injection was given to-day. In the
evening, patient wrote without any fatigue or disturbance, and
without support of his left hand for an hour and a half, A
very surprising result, but, unfortunately, this seeming success
proved deceptive.

Ibth. Careful observation has shown that the trouble is less
during the prevalence of high barometer, and dry, calm, and
clear weather ; the opposite conditions increasing it.

28^A. Complains as before of a wearing pain in the inside of
the wrist-joint, and calls attention to the fact that when the hand
is moved he can feel a distinct grating — which was, indeed,
quite audible to me. I took this to be the result of former
rheumatism, and ordered iodine ointment. In a couple of
weeks the grating ceased, the pain disappeared, and, wonderful
to relate, from that day he was no longer able to prognosticate
the weather by his wrist ! The state of the weather no longer
influenced his writing capacities either, for now he could
sometimes write well when the weather was bad, and again,
he would have trouble when it was fine. There remained no

268# CHOREA AND WRITER’S CRAMP.

doubt, therefore, that his writer’s cramp had been complicated
by rheumatism.

Dec, 11. The kneading of the forearm and hand, which
have been continued, are evidently useless. To-day I read for
the first time an account of Nussbaum’s apparatus, which was
at once sent for. The patient used it for a few days, but
experiencing no relief, gave it up.

Jan. 18, 1883. Condition unchanged. The patient distin-
guishes three stages in his daily condition, as follows :

First, a certain clumsiness is felt, then the writing becomes
more easy, then the third stage conies on, which is one of
fatigue and inability to control the mirscular actions.

No improvement has resulted from mechanical treatment.
He has made the following observations on the execution of
certain movements of the hand :

1. All movements from left to right and from below upward,
especially when these are curved, as in the letter w, are diflBicult
to make.

2. Attempted vertical lines are impossible, since they all
become curved to the left.

3. Horizontal lines become wavy.

4. All lines made from right to left and from above down-
ward become longer than intended.

5. At times writing proceeds without any diflSculty and
without any apparent cause for this improvement.

Feb. 6. Of all the means employed none have effected even
an improvement. There seems now to be no doubt that the
real cause of his trouble lies in a faulty mode of holding the
pen. The following figure (Fig. 116), drawn from life, shows
the cramped and strained position in which the fingers grasp
the pen. The callus on the middle finger is an evidence of the
excessive force with which the finger is pressed against the
pen (adducted), a testimony which is confirmed by the Datient’s
statement that he has actually broken pen-holders in two while
writing, simply from grasping them too firmly. In spite of
the unusual development of the muscles in his case, this
constant expenditure of continued muscular action only ends
in fatigue. For the sake of comparison, I have added an
illustration of the correct way of holding the pen. (Fig. 117.)

TBEATMENT OF WRITER'S CRAMP. *269

Unfortunately, although he has made every exertion, the
patient is no longer able to acquire the new method. He has
made the interesting observation that the muscles of the right

Fig. 116 . Fig. 117 .

forearm, as a result of manipulation, have increased consider-
ably in volume, the increase amounting to one and a half
centimetres.

Case XII. — A. Y,, aged fifty-two, a forestry oflicial from
Gmunden; poorly developed and of delicate constitution. In
1877, had gout in left lower and right upper extremities. The
subsequent sw^elling and deformity of the wrist and ankle were
cured by a course of sulphur baths in Baden, supplemented
by mechanical treatment at the hands of Dr. Kutscher, who
applied electricity to the hand and made the patient use rubber
balls. Motility was thus entirely restored to the stiffened
fingers, so that the patient was not only able to write again,
but to engage in elegant penmanship.

In May, 1880, fatigue, finally ending in cramp, was experi-
enced after prolonged wTiting.

In making the first few letters, the arm would be pronated,
but without pain, simply a feeling of complete disability of
the flexors occurring. Finally, the right hand becoming
entirely useless, he learnt to write with his left, and kept this
up for a year, when a weakness, unaccompanied by pain,
appeared in the left forearm, soon followed by cramps of
the fingers, in which the thumb and forefinger were extended

270

CHOREA AND WRITER^S CRAMP.

(Mr. V. says ‘‘ raised up the pen falling from the hand. He
then tried to use his right hand again.

Dr. Mayer, of Gmunden, ordered friction of the forearm
with chloroform. This caused a feeling of pleasant warmth,
and on the day following the patient w^as able to write more
readily. It was consequently continued, and with good results,
for writing became much more easy.

In the summer of 1881 he went to Baden again, and while
the sulphur baths there caused no amelioration of his trouble,
he was so much improved by faradization of the hand and
forearm, that writing with the right hand became possible
again, although the movements of the fingers were still
stiflF and the writing lacked all appearance of fluency.
Writing continuously for longer than half an hour was impos-
sible without a ten minutes’ rest. This was in the morning,
but in the afternoon the fatigue would become so marked that
after half an hour’s writing, half an hour’s rest would be
needed. He found that he could always write best on a
Monday, the Sunday rest having benefited him.

The appearance of the symptoms is as follows : As soon as
fatigue begins, tremor sets in, rendering further efltbrts useless.
The muscles of the thumb are the ones most aftected. “As
soon as I begin to write,” says the patient, “ the second phalanx
of the thumb, w’bich before was firm, grows soft, the skin over
it, as well as over the muscles composing the ball, becoming
wrinkled. Then pain in the arm gradually develops, and with
it, inability to write. Changes in the weather have no effect.
Mental emotions, on the other hand, react very markedly, their
effects often extending to the following day. Restless or
sleepless nights are bad for my condition. After resting for
some time an agreeable sensation of warmth spreads through
the hitherto cold hand and forearm, after which I can write
somewhat better again.”

In this case we may safely assume the cause of the trouble
to lie in overexertion, especially as the patient’s muscles gen-
erally were small and poorly developed. Nevertheless, although
poorly developed, he had for thirty years been able to write
with them from morning till night. It would seem as though
the attack of gout in the wrist had produced some degenera-

TBBATMENT OF WRITER’S CRAMP. -271

tion in the muscles and nerves, and that from that time on
they had never been able as before to respond to the exertions
required of them.

The case would come under the paralytic form of Benedikt’s
classification.

I recommended daily kneading of the flexors arising in the
forearm, and of the thenar and palmar muscles. Also passive
motion of the metacarpal bones, in order to affect the inter-
osseous and lumbrical muscles. As the patient lived some
distance from Aussee, I taught him the manipulations, and he
in turn taught them to his wife.

I further ordered him, the moment he felt fatigue, to stop
writing and to allow a stream of cold water to play upon his arm.

This treatment the patient carried out most conscientiously,
with the result that at the end of three months he could
write for from eight to ten hours without any return of the
old symptoms ; at the same time, the handwriting itself was
much improved. It is interesting to note here that writing
with a quill was easier than with a steel pen.

The following reports show the progressive improvements
which Mr. V. made.

First Report September 17, 1882. “ The condition of my
right hand is so far improved, that fatigue does not occur as
soon as formerly, but my grasp of the pen is still very insecure.
If I continue to improve as I have done, it will not be long
before I am well again.’’

Second Report September 22. “ Improvement continues.

Fatigue after prolonged writing not as great as before; other-
wise no change.”

l^hird Report October 8. “Allow me. my dear doctor, to
first answer the questions put to me in your favor of the 29th
of last month.

“ 1. Are the reports written slowly f At first the writing is not
exactly what would be called slow. It only becomes slow and
uncertain after fatigue sets in, which always occurs after I
have written for about two hours. There is no pain; only a
tiredness which disappears on resting half an hour.

“2. Is the handwriting normal f Not yet. Fluency is still
greatly lacking, the letters being unequal and angular. I
ascribe this condition to the lack of power in the muscles of the

272

CHOREA AND WRITER’S CRAMP.

forearm, and I suppose, therefore, that when these muscles have
been strengthened by the massage, this disability will vanish.
There has been no particular progress since my last report.^^

Fourth Report October 20. ‘‘As you will see by my writing,
considerable improvement has taken place. I can now write
at least two hours without experiencing fatigue, but rapid
writing is still impossible. I am very well pleased with my
progress.’’

Fifth Report November 10. “ I can now — thanks to the

method recommended by you, my dear doctor — write for
several hours without any difficulty. I have noticed, however,
that a quill suits me best, a steel pen seeming to irritate the
muscles of the arm. When fatigue begins there is a slight
twitching on the outer side of the forearm only, which dis-
appears after a fifteen minutes rest. My hand looks plumper
than it used to, and I notice considerable increase in power.”

Sixth Report December 3. “ Since I last wrote you, the

twitching, even after prolonged writing, occurs only occa-
sionally. Otherwise nothing new.”

Seventh Report January 14, 1883. “For some time I have
been so busy that it has been almost impossible for me to
attend to my private correspondence. As I am obliged to
write for eight or nine, often ten hours daily, Sundays and
holidays not excepted, I am surprised to find the condition of
my hand improving nevertheless. Were I only in the position
to follow your good advice, I have no doubt my progress would
be even more rapid. I still find I can write best with a quill,
and shall consequently avoid a steel pen for some time to come.
My handwriting may not be so elegant as formerly, but that is
of small account.

“ Recent trials with Nussbaum’s apparatus turned out quite
satisfactorily. In my opinion this contrivance might prove
very useful to anyone sufl:'ering from partial writer’s cramp,
but if the cramp attacks not only the fingers, but the forearm
as well, as was the case with my left forearm, I think it will
prove of little or no value.

“It is no aid to my right hand, because the seat of the

trouble lies in the forearm/^

(iciddim of » who baa so carefully traced all

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276

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277

•

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Chodin. Ueber die Anwendung der Massage bei Discissio cataractae. Proto-
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Pedraglia. Massage des Auges. Centralblatt fur praktische Augenheil-
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Bela Weiss. Anwendung der Massage bei Laryngitis catarrhalis und crou-
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Pagbnstecher. Ueber Anwendung der Massage bei Augenerkrankungen.

Schmidt’s Jahrbucher, 1881, iii. Bd., 189.

ScHREiBER. Massage als Mittel gegen die bei Tabes auftretende Anesthesie.
Wiener med. Presse, 1881, No. 10.

Dklhaes. Ueber die gleichzeitige Anwendung der Massage beim Gebrauch
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Boudet. Behandlung des Schmerzes mittelst mechanischen Vibrationen.
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Ritterfeld-Coneeld. Die Massage, popular-wissenschaftliche Darstellung
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P. Haufe. Ueber Massage, ihr Wesen und ihre therapeutische Bedeutung.
Frankfurt a. M., 1881.

Gussekbauer. Erfahrungen fiber Massage. Separatabdruck der Prager med.
Wochenschrift. Prag, 1881.

CHBONOLOGICAL BIBLIOGRAPHY.

279

Dally. De Pexercice m^tbodique de la respiration dans sea rapports avec la
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SCHREIBER Die Behandlung schwerer Pormen von Neuralgie und Muskel-
rheuraatismus mittelst Massage und methodischen Muskelubungen. Vor-
frag, gebalten in der 64. Versammlung deutscher Naturforscber und Aerzte
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Freund. Mittheilungen iiber die Bebandlung der Laryngitis crouposa und
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Weil. Der Restaurateur, ein elastiscbcr Kraft- und Muskelstarker fiir Zimmer-
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Post. Electromassage. New York Med. Record, xix., 1881.
Durand-Fardel. Du massage du foie dans Tengorgernent hepatique simple.
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Peters. Die Massagewirkung der MoorbMer. Berliner med. Wocbenscbrift,

1881, No. 34.

S. Klein. Ueber die Anwendung der Massage in der Augenbeilkunde.

Wiener med. Presse, 1882, Nos. 9, 10, 12, 15.

Granville Percussion as a Cure for Nervous Derangements. British Med.
Journal, March 11, 1882.

Gillette. Successful Application of Chloroform Narcosis and Massage in In-
tussusception. New York Med. Journal, September, 1882.

Averbeck. Die mediciniscbe Gymnastik. Stuttgart, 1882. Die Behandlung
der Milchknoten mit Massage. Med. Chir. Rundschau, 1882, Maiheft.
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A. Eulenberg. Ueber einige neuere Behandlungsversuche chronischer
Riickenmarkskrankheiten, naraentlich der Tabes dorsalis. Oesterreichi-
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Miinchner arztliches Intelligenzblatt, 1882, No. 39.

Eulenburg. Encyclopadie der mediciniscben Wissenscbaften, Artikel Mas-
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Schenkl. Ueber Massage des Auges. Lecture before the Wanderversamm-
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1882.

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Stein. Die Behandlung des Schreibekrampfes. Berliner klin, Wochenschrift,
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280

CHRONOLOGICAL BIBLIOGRAPHY.

Schott. Die Behandlung des Schreib- und Clavierkrampfes. Deutsche Medi-
cinal-Zeitung, 1882, No. 9.

Goodhart und Phillips. On the Treatment of Acute Chorea by Massage
and Kneading. Lancet, August, 1882.

Kkonlein. Ueber die chirurgische Behandlung des Ileus. Correspondenz-
“ blatt fiir Schweizer Aerzte, 1882, Nos. 16 u. 16.

Bitterlein. Darmverschluss, Kotherbrechen, Massage-Heilung. L’Union,

If/ 1882, No. 37.

Korbl. Behandlung der Lymphome. Wiener med. Wochenschrift, 1882,
No. 19

Engelmann. Massage and Expression, etc. American Journal of Obst., July,
1882.

Prochownick. Ziir Behandlung alter Beckenexsudate. Deutsche med.
Wochenschrift, 1882, No.s. 32 und 33.

Bunge. Beitrilge zur Massage des Unterleibs, insbesondere des Uterus und
seiner Adnexa. Berliner klin. Wochenschrift, 1882, No. 26.

Reibmayer. Die Massage und ihre Verwerthung in den verschiedenen Disci-
plinen der praktischcn Medicin. Wien, 1883.

Samuely. Ueber Massage fur die Bediirfnisse des praktischen Arztes bear-
beitet. Wien, 1883.

Stein. Ueber elektrische Massage und elektrische Gymnastik. Wiener med.
Presse, 1883, No. 2.

Beuster. Ueber den therapeutischen Werth der Massage bei centralen und
peripheren Nervenkrankheiten. Verhandlungen des Yereines fiir interne
Medicin in Berlin, 8. Januar, 1883.

Kochmann. Massage, erfolgreich bei Phlegmasia alba dolens. Allgemeine
med. Centralzeitung, 1883, 16.

Y. Aigner. Die Anwendung der Massage in den Acratothermen. Wiener
med. Presse, 1883, No. 21.

Operum. Yon der Massagebehandlung bei primetritischen Exsudaten. Gya-
col. obst. Med. d. Bl. I. Bd., 2. Heft. See also various manuals on obstet-
rics and gynecology.

Chroback. Handbuch der Frauenkrankheiten, revised by v. Billroth. Y. Bd.

Bandl, Hkgar und Kaltenbach. Die operative Gynakologie mit Einsch-
luss der gynakolog. Untersuchungslehre. Stuttgart, 1881. Also references
and abstracts in Schmidt’s Jahrbucher: Jahrgang 1877, Bd. cl., 173. —
Jahrgang 1879, Bd. clxxxiv. — Jahrgang 1880, Bd. clxxxvi. — Jahrgang
1881, Bd. cxcii. ; and in the Berichten des Krankenhauses Wieden (Wien)
1877 and 1878; and in Yirchow^s Jahresbericht, 1879, II. Bd. 2. Abthei-
lung.

INDEX

A bdominal massage in chronic
constipation, 250
in uterine disease, 195, lOO
muscles, cedematous, manipulations
of, 201

Abdomino- rectal massage in uterine
disease, 195, 196

Abdomino-vaginal massage in uterine
disease, 195, 196

Acid reaction of muscles during ac-
tivity, 48, 75

Active movements in cervico-brachial
neuralgia, 144-153
in chronic digestive derange-
ments, 241-248
in constipation, 240-248
in neurasthenia, 231
in palsies, 180

in sciatic and crural neuralgia,
106-127

in stiffness of joints and ten-
dons, 205-210

use of, in mechano-therapy, 73
Age, effect of, on treatment of sciatic
and crural neuralgia, 127
Anasmia, mechanical treatment of, 162
Anaesthesia and hyperaesthesia, mechan-
ical treatment of, 172
Apparatus used in treatment of cervico-
brachial neuralgia, 146.
149, 152

of chronic intestinal de-
rangements and consti-
pation, 246-252
of phthisis, 222
of writer’s cramp, 26 1

use of, in mechano-therapy, 39,

IWHi 77-83

Arthritic neuroses, mechanical treat-
ment of, 175
varieties of, 176

B ibliography, 27s

Bilateral sciatica, mechanical treat-
‘ ment of, 181

Billroth on value of massage in arthritic
neuroses, 176, 177

Bodily exercise, physiological effects
of, 86-97

C AUSES of portal congestion, 239
Calisthenics, 74

Cephalalgia, mechanical treatment of,
166, 161

Cerebral congestion, mechanical treat-
ment of, 236-238

Cervico-brachial neuralgia, mechanical
treatment of, 141

Cervico-occipital neuralgia, mechanical
treatment of, 165

Chemical effects of muscular work, 94
reaction of muscles during activity,
48, 76

Chloral poisoning, mechanical treat-
ment of, 185

Chloroform poisoning, treatment of,
182

Chlorosis, mechanical treatment of, 214,
216

Chorea, mechanical treatment of, 253
Clothing worn during manipulations,
71

Congestive oedemas, mechanical treat-
ment of, 201

Conjunctivitis, mechanical treatment
of, 211

Constipation, mechanical treatment of,
238, 241, 248, 250

Corneal opacities, mechanical treatment
of, 212

Crural neuralgia, mechano-therapy of,
104-127

D efinition of a sprain, i87

of massage, 31

Diabetes meilitus, mechanical treat-
ment of, 214, 234

Diagnosis, importance of correct, before
instituting mechanical treatment,
101

Digestion, effects of gymnastics on, 90
Digestive derangements, mechanical
treatment of, 238-252
Diseases suited to application of me-
chano-therapy, 98

Du Bois-Reymond on effects of bodily
exercise, 92

Duration of treatment of arthritic neu-
roses, 179

282

INDEX.

Duration of treatment of cervico-bra-
chial neuralgia, 153
of chronic constipation and in-
digestion, 252

of metritis and parametritis,
197, 198

of muscular rheumatism, 139
of sciatic and crural neuralgia,
127

of serous tendo-vaginitis, 193
of sprains, 190

of tonsillar and glandular hy-
pertrophy, 194

E mphysema of lungs, mechanical
treatment of, 23G-238
Episcleritis, acute and chronic, me-
chanical treatment, 211, 213
Exercises in treatment of chorea, 254
of constipation and indiges-
tion, 240-252

of phthisis and allied diseases,
218-229

muscular, physiological effects of,
216

Eye diseases, mechanical treatment of,
210

F at, effects of gymnastics on deposi-
tion of, 89

Fever, applicability of mechano-the-
mpy during, 170

Flagellations in narcotic poisoning, 183

G ASTEITIS, chronic, mechanical
treatment of, 214

Glandular enlargements, mechanical
treatment of, 193

Glaucoma, mechanical treatment of,
213

Gymnastic therapeutics, Hoffman on,
25

Gymnastics, physiological effects of, 86
sanitary, 74
use of, in chorea, 253

in chronic digestive derange-
ments and constipation, 241-
248

in phthisis, 218

H acking in cervico-brachial neu-
ralgia, 146

in mechano-therapy, 61
in sciatic and crural neuralgia, 115,
116

Hand, value of, over apparatus in mani-
pulations, 39

Headache, mechanical treatment of,
161, 163

Heart and circulation, effect of gym-
nastics on, 87

Heat, generation of, in muscles during
mechanical vibration, 49

Hemorrhoids, mechanical treatment of,
286

History of mechano-therapy, 17-30

Horizontal bar, use of, in phthisis, 226
in sciatic and crural neu-
ralgia, 106

Hyperaesthesia, mechanical treatment,
of, 173

Hypertrophied tonsils, treatment of, 193

Hypochondria, mechanical treatment
of, 214-232

Hysteria, mechanical treatment of, 214,
229, 282

Hysterical joints, mechanical treatment
of, 175

I DIOSYNCKASY, effect of, on treat-
ment of sciatica, 127
Indigestion, mechanical treatment of,
238

Innervation of bloodvessels, a result of
mechano-therapy, 44
Intercostal neuralgia, mechanical treat-
ment of, 156, 160
Introduction, 17

J ACKSON, A. BEEVES, on mas-
sage in treatment of uterine dis-
ease, 196

Joints, neuroses of, mechanical treat-
ment of, 175

stiffness of, mechanical treatment
of, 204

K ERATITIS, mechanical treatment
of, 213

Klemm’s muscle-beater, 62

L abile mechanical interferences, 66
Laisne’s method of treating chorea,
254-257

Ling’s method of mechano-therapy, 28-
80, 75

Lumbago, mechanical treatment of,
140, 166

M anipulations in cervico-bra-

chial neuralgia, 144-168
in chronic metritis and parame-
tritis, 194-198

INDEX.

288

Manipulations in congestive cedemas,

201

in constipation, 240
in eye diseases, 210
in hysteria and hypochondria, 233
in mastitis, 193

in mechano-therapy, description
of, 51-72

in muscular rheumatism, 165
in narcotic poisoning, 183
in neurasthenia, 231
in oedematous abdominal walls,
201

in palsies, 179
in phthisis, 218

in sciatic and crural neuralgia,
106

in sprains, 187

in stiffness of joints and tendons,
204

in synovitis and tendo-vaginitis,
191, 192

in tonsillitis and glandular enlarge-
ment<, 193

of skull, care necessary in, 158
Massage and mechano-therapy, use in
general firactice, 37
definition of, 31
diseases suited to application
of, 98

general, in emphysema, 237
in congestive oedemas, 201-203
in crural neuralgia and sci-
atica, 104-127

in neurasthenia and allied af-
fections, 231

in abdominal tumors, 201-203
in sprains. 186
in uterine diseases, 194-198
in writer’s cramp, 263
ocular, 210

suitability of, in recent eases,
138

use of, by general practitioner,
37

by non-physicians, 38
Mastitis, mechanical treatment of, 193
Mechanical interferences, physiological
effects of, 4 1-49
varieties of, 51
labile, 66
stabile, 54

Mechano-therapy, diseases suited to ap-
plications of, 98
history of 17-30

Buitab.lity of, in recent cases, 138
use of apparatus in, 39, 77-93
•Megrim, mechanical treatment of, 163
Metritis, mechanical treatment of, 194-
198

Mind, effects of gymnastics on, 91-97

Moral inf uence, value of, in treatment
of arthritic neuroses, 178
Movements, active, use of, in mechano-
therapy, 67

passive, use of, in mechano-therapy,
73

Movement-cure, Swedish, 74
Myalgia, mechanical treatment of, 100
Muscle-beater, Klemm’s, 62
Muscles, acid reaction of, during ac-
tivity, 48, 75

involved in cervico-brachial neu-
ralgia 143

in cervico-occipital neuralgia,

155

in muscular rheumatism, 166
in sciatic and crural neuralgia,
105

in writer’s cramp, 258, 259,
263-264

Muscular contraction, an effect of me-
chano-therapy, 46
exercise, chemical changes follow-
ing, 94

physiological effects of, 86-97
in phthisis, 216

rheumatism, mechanical treatment
of, 100, 164

EURASTHENIA, nature of, 229
treatment of, 229-231
Neuralgias and muscular rheumatism,
mechano-therapy of, 106
Neuroses, arthritic, treatment of, 175
Nerves, effects of mechano-therapy
upon, 44-49

Nervous system and mind, influence of
gymnastics on, 91

Nussbaum’s apparatus for writer’s
cramp, 261

O CULAR massage, 210

(Edema, mechanical treatment of,
201

Oil, use of, in manipulations, 69
Ointments, use of, in ocular massage,
213

Opium poisoning, mechanical treat-
ment of, 182

Ovarian cysts, treatment by massage,
202-203

P ALSIES, mechanical treatment of,
179

Parallel bars in treatment of phthisis,
222

284

INDEX.

Paralytic form of writer’s cramp, treat-
ment of, 263

Parametritis, mechanical treatment of,
194-198

Pathogenesis of muscular rheumatism,
166

Passive movements in cervico-brachial
neuralgia, 144

in chronic indigestion and
constipation, 248-252
in lumbago, 168
in palsies, 180

in sciatic and crural neural-
gias, 106

in stiffness of joints and ten-
dons, 205

in writer’s cramp, 203
results of, 67

Pelvic exudations, mechanical treat-
ment of, 195-198

Phthisis, mechanical treatment of, 214-
229

Physiological effects of gymnastics, 94
of mechanical interferences,
41-50 I

Pinching in rnechano-therapy, 04
Pneumatic treatment of emphysema, ,
237 I

Poisoning by opium, chloroform, and I
chloral, mechanical treatment of, 182 '
-185

Pressing in mechiano-therap}’, 54
Pressure, rotatory, in treatment of lum-
bago, 160

Prognosis of cervico-brachial neural-
gia, 153

of glandular and tonsillar enlarge-
ments, 194

of sciatic and crural neuralgia, 127
Psychopathies, mechanical treatment
of, 232

R espiration, effects of gymnas-
tics upon, 90

Rings, hanging, exercises upon, in
chronic indigestion and constipation,
246

Rotatory pressure in lumbago, 166
Rubbing and stroking in mechano-
therapy, 66

Rhythmic exercises in chorea, 254

OIATIC and crural neuralgia, mo-
chano-therapy of, 104-127
Skin and kidneys, effects of gymnastics
on, 89

Spastic form of writer’s cramp, treat-
ment of, 268

Sprains, mechanical treatment of, 140

Squeezing in rnechano-therapy, 66
Stabile mechanical interferences, 54
Stift'-neck, rapid treatment of, 140
Stiffness of joints and tendons, mechan-
ical treatment of, 204
Stroking and rubbing in mechano-
therapy, 166

Sugar in urine, effect of exercise upon,
in diabetes melitus,235
Swedish movement-cure, description
of, 74

Synovitis, mechanical treatment of, 191

T abes dorsalis, mechanical treat-
ment of pariesthesiie of, 173
Tapping, in rnechano-therapy, 58
Temperature, increase of, an effect of
mcchano-'hera})y, 45
Tendons, stiffness of, treatment of, 204
Tendo-vaginitis, treatment of, 192
Thrusting in rnechano-therapy, 58
Tonsillitis, mechanical treatment of, 198
Torticollis, mechanical treatment of,
170

Treatment, mechanical, of ansemia of
headaches, 162

of anaesthesia and hyperass-
thesia, 172

of arthritic neuroses, 3 76
of cephalalgia, 156, 161
of cerebral congestion, 236-
238

of cervico-occipital neuralgia,
141, 155

of chloral poisoning, 185
of chlorosis, 214, 216
of chorea, 253

of chronic digestive derange-
ments, 238-252
gastritis^ 214, 215
metritis and parametritis,
194

of constipation, 238
of eye diseases, 210
of glandular enlargements,
193-196

of hemorrhoids, 236
of hypochondria, 214, 282
of hysteria, 214, 232
of hysterical joints, 175
of intercostal neuralgia, 166-
160

of lumbago, 140, 166
of mastitis, 193
of muscular rheumatism, 100,
164

of myalgia, 100
of neuralgias and muscular
rheumatism, 100
of neurasthenia, 229

INDEX.

285

Treatment, niechanical, of oedemas, 201
of opium and chloral poison-
ing, 182
of palsies, 179

of psychopathies, 232 j

of pulmonary emphysema, 236 |
of sciatic and crural neuralgia, !
104-127

of sick headache, 103 '

of sprains, 186

of stiffness of joints and ten- !

dons, 204 j

of synovitis, 191 j

of lendo-vaginitis, 192 !

of tonsillitis, 193 i

of torticollis, 140, 170 j

of trigiemnal neuraltria, 156 i
of writer's cramp, 257 I

Trigeminal neuralgia, mechanical j
treatment of, 156

Tumor, dissipation of, by massage,
case illustrating, 198
Tumors, abdominal, massage in, 201

U NILATERAL sciatica, case illus-
trating mechanical treatment of,
129

Urine, effect of exercise upon amount
of sugar in, in diabetes rnellitus, 235,
236

W RITER’S cramp, cases illustrating
mechanical treatment of,
206-273

manipulations, in paretic form
of, 263

mechanical treatment of, 257
Niissbaum's apparatus for, 260
varieties of, 258

CATALOGUE

OF THE

MEDICAL PDBLICATIOHS

ISSUED BY

YOUNG J. PENTLAND,

EDINBURGH AND LONDON.

EDINBURGH : ii TEVIOT PLACE.
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OOTOBEB 1889.

PROSPECTUS.

STUDIES IN CLINICAL MEDICINE.

Under the above Title is published every alternate Friday (Summer Session 1889
and Winter Session 1889-90), a record of some of the work done at Dr. Byrom
Bbamwell’b Out-Door Clinic in the Edinburgh Royal Infirmary.

The “ Studies ” consist of Cases drawn from all departments of Clinical Medicine.
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remarks, are, so far as circumstances allow, published verhatirn.

Each number comprises 16 pages crown quarto, handsomely printed on a specially
made toned paper. Illustrations, consisting of Wood Engravings, Lithographs, and
Chromo-Lithographs, are liberally introduced into the text.

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THE

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MEDICAL SCIENCES.

EDITED BY

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YOUNG J. PENT LAND,

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SYNOPSIS OF THERAPEUTICS

ARRANGED FOR THE USE OF PRESCRIBERS:

WITH POSOLOGICAL TABLE AND AN ARRANGEMENT OF THE POISONS.

By R. S. AITCHISON, M.B., Edin.

(1886.)

EXTRACT FROM THE PREFACE.

The object of this short work has been to collect and to group in synoptical
form, the agents comprising the Materia Medica. Instead of a natural history
or alphabetical arrangement, a therapeutic classification has been adopted. This
consists in grouping the drugs, according to their physiological action and their
uses in practice — a plan which has the obvious advantage of enabling the pre-
scriber readily to see the various remedies available for any morbid condition,
and to make his selection accordingly.

CONTENTS,

Medicines which act upon the —

Heart, etc. — ^Vascular stimulants, Vascular sedatives, Vascular tonics.

Lungs, — Pulmonary stimulants, ( Expectorants Pulmonary sedatives.

Kidneys, etc. — Diuretics ( stimulating Diuretics (sedative)^ Diuretics ( indirect )y Lithon-
triptics, Vesical and Urethral alteratives.

Skin, — Diaphoretics, Sudorifics, Diaphoretics ( stimulatmg )y lyiaphoTotioa ( sedative )y Dia-
phoretics ( assistants ).

Digestive System, — Emetics, Stomachic and Enteric stimulants, ( carminatives Jy Stomachic
and Enteric Sedatives, Stomachic and Enteric Tonics, ( digestcmts )y Pur^tives, Cath-
artics, LaxativeSy SimpUy BrastiCy HydragoguSy SdLvney Cholagogues, Aajuvards, An-
thelmintics.

Nervous System, — Exhilarants, Narcotics, Anodynes, Soporifics, Sedatives, Anaesthetics,
Spinal Stimulants, Spinal Sedatives, Aphrodisiacs, Anaphrodisiacs, Antispasmodics,
Nervine Tonics and Antiperiodics.

Uterus, — Emmenagogues and Ecbolics.

Pupils, — Mydriatics, Myositics.

Systemic Kemedies, — Blood Tonics, Alkaline or Antacid medicines, Acids and Astringents
Refrigerants, Antipyretics, Alteratives.

External Remedies, — ^Rubefacients, Epispastics, Pustulants, Caustics and Escharotics,
Local Astringents and Styptics, External Sedatives, Local Anaesthetics, External

.... TT.. , j__ 1 A pnd

Clothe pp. X., 320, with 9 tllustraiions^ jrricc ys. uu.

THE

TREATMENT OF EPILEPSY.

WILLIAM ALEXANDER, M.D., F.R.C.S.,

HONORARY SURGEON, ROYAL SOUTHERN HOSPITAL, LIVERPOOL; VISITING SURGEON,

LIVERPOOL WORKHOUSE HOSPITAL; ACTING HONORARY CONSULTING
SURGEON, EPILEPTIC INSTITUTION, MANOR HOUSE, MAGHULL.

{1889.)

EXTRACT FROM PREFACE.

With the close of the chapter just referred to (Vertebral Artery^ Ligature
of the, Heath's “Dictionary of Practical Surgery,” vol. II., page 786), my
interest in epilepsy did not cease. Indeed, at the time the article referred to
was written, most of the investigations and operations now about to be
described were complete, and time alone was wanting to realise their value.
Sufficient time has now elapsed to test results, and these results are so
encouraging and so interesting that I do not think I should withhold them any
longer from the profession.

A description of the effects of removal of the cervical ganglia of the
sympathetic for epilepsy forms the chief feature of this book, and is the cause
of the book being written. Other methods of treatment are, however, touched
upon, but only as far as the light of my own experience enables me to speak.
The tenth chapter I consider of great importance, and I trust it may be useful
in bringing about in Britain a more organised, rational, and successful method
of dealing with epileptics.

SUMMARY OF CONTENTS.

Chapter I. — Introduction.

Chapter II. — Theories that influenced the Author in his investigation of Epilepsy, and that
guided his attention to the sympatddetic system.

Chapter III. — ^How it was ascertained that removal of the superior cervical ganglion was
capable of being done with safety upon niixn, and the description of the
operation.

Chapter IV. — Reports of Cases in which the superior cervical ganglia of the sympathetic
were removed, with summary of results up to the present time, i.e., four to
six years after operation.

Chapter Y. — Physiological effects produced by the removal of the superior cervical ganglia
of the sympathetic in the lower animals and in man.

Chapter VI. — The Influence of Reproduction on Epilepsy.

Chapter VII. — Trephining for Epilepsy.

Chapter VIII. — Medicinal and Dietetic Treatment of Epilepsy.

Chapter IX. — ^Percussion and Galvanization of the Spine, and sundry minor operations for
Epilepsy.

Chapter X. — General Treatment of Epilepsy, with an account of a visit to Bielefeld, and the
establishment of Manor House. Maghull.

Chapter XI. — ^Morbid Anatomy of Epilepsy Cases observed by Author, and concluding
remarks upon.

In Three handsome volumes^ Royal 8w, containing about looo pages eachj with
fully 1700 elaborate Illustrations^ Price 308 ./^/* volume nett.

THE AMERICAN SYSTEM OF

DENTISTRY,

IN TREATISES BY VARIOUS AUTHORS,

EDITED BY

WILBUR F. LITCH, M.D., D.D.S.,

PROl-ESSOR OF VKOSTIIETIC UENTIhTRY, THERAPEUTICS, AND MATERIA MF.DICA,
IN THE PENNSYLVANIA COLLEGE OF DENTAL SURGERY, PHILADELPHI V,

EXTRACT FROM THE PROSPECTUS.

“Dentistry, although as old as history itself, yet owes its practical and
scientific advanct!iiK5iit mainly to the labours and researches of the last two
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understand and expound the whole extent of tlie subject is far beyond the
] lowers of any single mind and pen. To the fiu'ther dissemination of dental
learning, the gathering of this widely scattered mass of knowledge into a com-
pact and orderly body is essential, and a 'work which will accomplish this end
promises to mark an era in the science by reflecting its present position and in-
dicating the direction in which future research is likely to prove most successful.

“ Such a wort — The American System of Dentistry — has for some years
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“ The distinguished editor has chosen those men who, by long experience
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“ In short, ‘ The American System ’ forms a complete Encyclopasdia of the
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A Detailed Prospectus will be sent to any address on application.

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SYSTEM OF

GYNECOLOGY & OBSTETRICS,

BY AMERICAN AUTHORS.

EDITED BY

MATTHEW D. MANN, A.M., M.D.,

PROFKSSOR OF OBSTETRICS AND GYNECOLOGY IN THE MEDICAL
DEPARTMENT OF THE UNIVERSITY OF BUFFALO, N.Y.

AND

BARTON COOKE HIRST, M.D.,

ASSOCIATE PROFESSOR OF OBSTETRICS IN THE UNIYERSITV OF PENNSYLVANIA;
OBSTETRICIAN TO THE PHILADELPHIA MATERNITY HOSPITALS;
GYNECOLOGIST TO THE ORTHOP,iEDlC HOSPITAL.

EXTRACT FROM THE PROSPECTUS.

The Publisher has much pleasure in announcing to the Profession that
this enterprise, which has been long and carefully elaborated, is now completed.

The subjects treated are those which American Medicine has made
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That the time has arrived for the presentation of these subjects is shown
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Each volume is copiously indexed and the final volume of each section contains
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CLINICAL STUDIES ON

DISEASES OF THE EYE,

Including those of the Conjunctiva, Cornea, Sclerotic, Iris,
and Ciliary body.

By Dr. F. RITTER VON ARLT,

PROFESSOR OF OPHTHALMOLOGY IN VIENNA.

Translated by Dr. LYMAN WARE,

SURGEON TO THE ILLINOIS CHARITABLE EYE AND EAR INFIRMARY *, OPHTHALMIC
SURGEON TO THE PRESBYTERIAN HOSPITAL, AND TO THE
PROTESTANT ORPHAN ASYLUM, CHICAGO.

(i88s)

EXTRACT FROM PREFACE.

My object in publishing this work was primarily to give the physicians
engaged in general practice a book of reference which they could consult
regarding the common and most frequent diseases of the eye. I also hoped
that I could induce them to reflect more upon the various morbid processes, and
to inquire into their exciting causes. To determine this etiological relation for
each individual case is no less important for the practising physician (on
account of prognosis and therapy, and often, too, with reference to questions of
sanitary science and forensic medicine) than to find out in which part of the
organ the disease is located, what anatomical changes have taken place, and
what changes are stdl likely to occur, according to general principles and our
own experience. Such has been the aim in view in the preparation of this book.

Third Edition, 8z/o, Cloth, pp. 310, with no Wood Engravings, Price lOS. 6d.

MEDICAL ELECTRICITY:

A Practical Treatise on the applications of Electricity to
Medicine and Surgery.

By ROBERTS BARTHOLOW, A.M., M.D., LL.D.,

PROFESSOR OF MATERIA MEDICA, GENERAL THERAPEUTICS, AND HYGIENE IN THE
JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA.

^VMMARY OF CONTENTS.

(1887.)

Part I. — ELECTRO-PHYSICS. — Magnetism. Static Electricity. Dynamical Elec-
tricity. Forms of Galvanic Combinations. Electro-Magnetism. Magneto-Electricity.
Electro-Magnet and Magneto-Electric Batteries for Medical use. Case of Batteries,
Galvanic and Faradic : Manipulation.

Part II. — ELECTRO-PHYSIOLOOY . — ^Animal Electricity. Action of Galvanic
current on motor, sensory, and mixed nerves. Action of induced or Faradic currents on
motor, sensory, and mixed nerves. Action of Galvanic and Faradic electricity on the sympa-
thetic and vasomotor systems. Action of Galvanic and Faradic Electricity on musrie,
striated and non-striated. Action of Galvanic and Faradic currents on the cerebro spinal
axis. Action of Galvanic and Faradic currents on the pneumogastric nerve and heart.
Action of Electricity on the special senses.

Part III. — ELECTRO-DIAGNOSIS . — ^Electro-contractility, Electro-sensibility.

Part lY.—ELECTRO-THERAPEUTICS.^UQ^Bto-Y\ierB.^y. Static Electricil^r, its
methods and uses. Electro-Therapeutics. Electricity in spasm and cramp. Electricity in
the paralyses. Electricity in the treatment of pain. Electricity in aneesthesia and analgesia.
Electricity in the vasomotor and trophic neuroses. Electricity in constitutional diseases.
Electricity in local, other than nervous diseases.

Part Y. ^ELECTRICITY IN Electrolysis. Medical electric heating

and lighting.

Part VI. — THERMO-ELECTRICITY. — ^Principles. Medical uses of the Thermo-

Electric pole.

Sw, Cloth, fp. viii. 374, with 408 Illustrations, jinuy im

awl 4 analytical tables. Price lOS* fid*

TEXT-BOOK OF

GENERAL BOTANY

Dr. W. J. BEHRENS.

TRANSLATION PROM THE SECOND GERMAN EDITION.

KEVISEU BY

PATRICK GEDDES, F.R.S.E.,

PROFESSOR OP BOTANY IN THE UNIVERSITY OF DUNDEE

(188S)

EXTRACT FROM THE PREFACE.

To introduce to the English student a text-book which has so rapidly
attained wide circulation and usefulness throughout the schools and colleges of
the German-speaking countries, little preface or eulogium is necessary. The
Author’s fl-iTTi has been twofold ; he has endeavoured not only to explain in the
simplest language the elementary facts of Vegetable Anatomy and Histology,
of Physiology and Classification, but also to awaken the interest and enthusiasm
of the student from the very outset, by introducing him to the fresher fields of
the science, and by setting before him many of the latest and most interesting
results of their exploration ; so placing him, as the title of the original work has
it, “at the newest standpoint of the science.” In this relation, it is only
necessary to refer to part in., or, more particularly to the section on the Ferti-
lisation of Flowers. In the systematic portion, the student will find the diffi-
culty of mastering the Natural Orders diminished in practice by the help of the
Analytical Tables, and even more by the broad and simple grouping of the
orders into their larger alliances.

EXTRACTS PROM PRESS NOTICES.

** The work now before us is written in such a plain and simple style, and withal is so
interesting, as to invest the study with a charm which makes it difficult for one to put down
the book ; and we are not surprised to hear that it has rapidly attained wide circulation. It
only requires to be known to become a popular class-book.” — Students^ Journal.

** A most useful addition to the list of text-books on this subject, and one that may be
highly recommended to teachers of the science. The illustrations are original and exceedi^ly
good.” — Journal of Microscopy.

“We have no hesitation in stating our belief that this is the best Botanical Text-Book
for medical students in the English language.” — Bristol Medical Journal.

“ To a rare faculty for simple exposition the author adds a wide acquaintance with the
latest developments of the science, and he contrives to carry the student along with him from
the enunciation of its most rudimentary phenomena and principles to the consideration of
its highest problems. These characteristics of the work have been faithfully preserved in the
present translation. . . . Altogether the work is not only an excellent text-book, but is

admirably adapted to serve the purposes of the lay reader.” — ScotsTnan.

“ A fascinating book on a fascinating subject is Mr Geddes’ translation of Dr Behrens’
* Text-Book of Botany.’ The author of tliis volume has contrived to invest its learned aspects
with something of the romance attaching to its sentimental associations. He builds up the
science from its elementary facts to its most complicated problems in a manner interesting to
follow and easy to master. The fertilisation of flowers forms the subject of a delightful
section. Those who care nothing for Botany as a science can scarcely fail to enjoy the account
of such things as given in these pages ; wMIg students of the science may rest assured that,
popular as the style of this work is, it is yet thoroughly trustworthy.” — Literary World,

“ In every respect the work is an excellent class-book, and we have no doubt that it will
speedily find favour with teachars and students.” — Glasgow Herald.

8 Wf Cloth^ gilt topypp, XX., 678, illustrated with a large series of Coloured
Plates from original drawings^ Price 25s.

DISEASES OF THE EYE.

A PRACTICAL TREATISE FOR STUDENTS
OF OPHTHALMOLOGY.

GEORGE A. BERRY. M.B., F.R.C.S.Ed.,

OPHTHALMIC SURGEON, EDINBURGH ROYAL INFIRMARY; SENIOR SURGEON,

EDINBURGH EYE DISPENSARY; LECTURER ON OPHTHALMOLOGY,

ROYAL COLLEGE OF SURGEONS, EDINBURGH.

(Pentland’s Medical Series— Volume Second.)

EXTRACT FROM PREFACE.

(1889.)

In the following pages I have endeavoured to give a description of the
principal Diseases which affect the Eye, or lead in any way to impaired vision.
The symptoms and treatment of these diseases are discussed more or less fully
according to their importance. Except in cases w'here it has some direct
bearing on the treatment to be adopted, I have either altogether omitted any
mention of Pathological Anatomy, or have devoted a relatively small space to it.
This I have done for various reasons, — the main one being that I believe any
exhaustive discussion of the Pathological Anatomy of Eye Diseases tends to
divert attention from their clinical aspects. The objective examination of the
eye, and the subjective examination of its functions, are capable of affording
sufficient information for all practical purposes.

The clinical study can therefore very well be carried on without much
attention to the details of Pathology. In order to avoid repetition, and to
facilitate reference* to Operations which are performed for several different
affections of the Eye, aU the principal Operations are discussed in the last
chapter.

SUMMARY OF CONTENTS.

Chapter I. — Diseases of the Eyelids and Lachrymal Apparatus.
Chapter II. — Diseases of the Conjunctiva.

Chapter III. — Diseases of the Cornea.

Chapter IV. — Diseases of the Crystalline Lens.

Chapter V. — Diseases of the Iris and Ciliary Body.

Chapter VI. — Diseases of the Choroid and Vitreous.

Chapter VII. — Glaucoma.

Chapter VIII. — Porcign Bodies in the Eye.

Chapter IX. — Sympathetic Ophthalmitis.

Chapter X. — ^Diseases of the Ketina and Optic Nerve.

Chapter XI. — Amblyopia, Amaurosis, and other anomalies of vision.
Chapter XII. — Intraocular Tumours.

Chapter XIII. — ^Diseases of the Orbit.

Chapter XIV. — ^Errors of Eefraction and Accommodation.

Chapter XV. — Affections of the Oculo-Motor Muscles.

Chapter XVI.« — Examination of the Eye.

Chapter XVII. — Operations.

General Index.

Index op Authors.

2 A

Large 8 w, Cloth^ pp, xvL, 783, Price 25s. Illustrated with 226 Wood
Engravings^ and 68 pages of Lithograph Plates^ exhibiting 91 Figures — 317
Illustrations in all.

DISEASES OF THE HEART

AND THORACIC AORTA.

BYROM BRAMWELL, M.D., F.R.C.P.Ed.,

LECTURER ON THE PRINCIPLES AND PRACTICE OF MEDICINE, AND ON PRACTICAL MEDICINE AND MEDICAL
DIAGNOSIS, IN THE EXTRA-ACADEMICAL SCHOOL OF MEDICINE, EDINBURGH ;

ASSISTANT PHYSICIAN, EDINBURGH ROYAL INFIRMARY.

EXTRACTS FROM PRESS NOTICE^.

From the Lancet. — “In this elegant and profusely illustrated volume,
Dr. BramweliL has entered a field which has hitherto been so worthily occupied
by British authors ; and we cannot but admire the industry and care which he
has bestowed upon the work. As it stands, it may fairly be taken as repre-
senting the standpoint at which we have arrived in cardiac physiology and
pathology, for the book opens with an extended account of physiological facts,
and especially the advances made of late years in the neuro-muscular mechanism
of the heart and blood-vessels. Although in this respect physiological research
has outstripped clinical and pathological observation, Dr. Bramwell has, we
think, done wisely in so introducing his treatise, and has thereby greatly added
to its value. ... A chapter on thoracic aneurism terminates a work which,
from the scientific manner in which the subject is treated, from the care and
discrimination exhibited, and the copious elaborate illustrations with which
it is adorned, is one which will advance the author’s reputation as a most
industrious and painstaking clinical observer.”

From the Medical Times. — “Among the host of text-books and mono-
graphs which come now from the medical press, it is thoroughly gratifying to
occasionally find some which do not bear obvious marks of being written either
to order or for the mere sake of writing. I^either inaccuracy nor airing of
crotchets — two faults which so largely disfigure our literature — can be charged
against the work which is now before us. Those who have read Dr. Bram-
wbll’s previous book on the Spinal Cord would rightly expect to find the result
of careful labours set forth with systematic clearness in anything that came
from his pen ; and they will not be disappointed in their perusal of this treatise
on the Diseases of the Heart. Although this book deals systematically with
the subject, and therefore contains much that is to be found in other works, it
has two characteristics which entirely preclude the objection that it is super-
fluous, and, moreover, give it a right to rank among the most useful of English
texb-books. In the first place, the matter is arranged with great clearness, and
the style is particularly intelligible, being neither redundant nor over-condensed.
In the second place, there are signs throughout the work that it is not simply
a careful compilation, but that the author has thought out for himself the
problems he discusses, and has made the subject his own by assiduous work,
both clinical and pathological. The book ends with a most valuable one
(chapter) on Diseases of the Aorta, in which good use is made of rich patho-
logical material. The illustrations are of great merit, and cannot fail to give
a vivid idea of the conditions underlying the often obscure symptoms of intra-
thoracic disease. A careful perusal of this work will well repay the student
and refresh the memory of the busy practitioner.”

Second Edition^ Revised and Enlarged^ 8 w, Cloth^ pp, xvi., 360, illustrated
with Wood Engravings and 53 pages of Lithograph Plates printed in Colours
— 183 Illustrations in all^ Price l6s.

DISEASES OF THE SPINAL CORD.

BYROM BRAMWELL, M.D., F.R.C.P.Ed.,

LECTURER ON THE PRINCIPLES AND PRACTICE OP MEDICINE IN THE EXTRA ACADEMICAL SCHOOL OP
MEDICINE. EDINBURGH; ASSISTANT PHYSICIAN TO THE EDINBUPGH ROYAL INFIRMARY.

(1884.)

SUMMARY OF CONTENTS.

Chapter I. — The Anatomy and Physiology of the Spinal Segment.

Chapter II. — The General Pathology of the Spinal Segment. — The Alterations in
function which result from lesions of its (Afferent parts.

Chapter III. — Method of Case-taking. — Summary of Symptoms met with in Diseases of
the Spinal Cord. — The Clinical Examination of a qase of Spinal Cord Disease. — General Plan
of the Diagnosis. — General Plan of the Prognosis. — General Plan of the Treatment.

Chapter IV. — Tabular Classification of the Diseases of the Spinal Cord. — ^Description
of the Individual Affections.

Appendix. — ^Pseudo-H3rpertrophic Paralysis. — Directions for the post-mortem Examina-
tion and Preservation of the Spinal Cord.

EXTRACTS FROM PRESS NOTICES.

From the Lancet. — “ The mode in which the author thus introduces us to the anatomy,
and proceeds in the same way to the physiology and pathology of the spinal cord, through
the medium of a single segment of it, is philosophical, and tends much to clearness of illustra-
tion. . . . Dr. Beam WELL enters very fully, and with much lucidity of description, upon

the important subject of case-taking. ... A couple of pages are well devoted to the
subject of ‘ pain referrf d to the spinal column,’ a point which we believe is constantly giving
rise to mistakes. The question of the diagnosis in diseases of the spinal cord receives, as it
deserves, full attention, and many valuable points are contained in the portion of the work
relating to this subject. Some good remarks also occur in reference to prognosis, a subject
upon which, unfortunately in the nature of things, there is not very much to be said of a
satisfactory character. The same remark may perhaps be applied to the question of treat-
ment. What little more is to be said upon this matter is sensibly put.”

From the British Medical Journal.— “The work before us brings before its readers
a complete resume of all the recent investigations on the subject both at home and abroad.

. It professes to place before the student and the profession all that is known
of the subject it imdertakes to elucidate. Considering the enormous difficulties to be
encountered in the task, this has been carried out in a masterly manner, and evidently by
one who has thoroughly and practically acquainted himself with all the details of the
inquiry. . . , Mext is discussed the pathological condition of the cord, and this is

done in an equally clear and convincing manner. Dr. Bkamwell, while continuing to
employ the diagrammatic method to explain his views, supplements it by what constitutes
one of the chief attractive features of his book. This consists of a series of exquisitely
artistic chromo-lithographs of original sections of the cord in health and disease, prepared
and drawn by himself. We have never seen anything more beautifully display^, and we
congratulate the author on the successful manner in which they have been executed. . . .

The work, as a whole, we can strongly recommend to our readers. It is evidently the
outcome of experience, labour, and thought. Although simple, clear, and concise, it brings
before the profession a complete and exhaustive statement of one of the most difficult and
complex problems in the whole range of medicine.”

From the Journal of Mental Science. — “His chromo-lithographs are the best we
have seen in any book on the diseases eff the nervous system. . . . It is not a slavish

compilation, in which all kinds of facts, relifble and unreliable, are heaped together without
any regard to their value. On the contrary, there are constant evidences that Dr. Bramwell’s
reding has been tested by experience at the bedside and in the pathological room.”

2iV0^ Cloih^pp* xvi., 270, with 116 Illustrations^ Price 14s.

INTRACRANIAL TUMOURS.

BYROM BRAMWELL, M.D., F.R.C.P.Ed.,

LECTURER ON THE RRINXIPLES AND PRACTICE OF MEDICINE IN THE EXTRA-ACADEMICAL SCHOOL OF
MEDICINE, EDINBURGH ; ASSISTANT PHYSICIAN TO THE EDINBURGH ROYAL INFIRMARY.

(1888.)

SUMMARY OF CONTENTS,

Chapter I. — Definition. — ^Introduction. — Etiology. — General Pathology,
or Pathological Physiology.

Chapter II. — Symptoms and Chnical History. — Analysis of Individual
Symptoms.

Chapter III. — Changes in the Eundus Oculi. — Double Optic Neuritis and
Optic Atrophy.

Chapter lY. — Motor Derangements. — Paralysis. — Spasm. — Tremor.
— Contracture.

Chapter Y. — Sensory Derangements. — ^Touch. — Sight. — Hearing. — ^Taste.
— SmeU.

Chapter YI. — Mental Alterations. — ^Aphasia. — ^Apoplectic Attacks. —
Yisceral Derangements.

Chapter YII. — ^Diagnosis and Difierential Diagnosis.

Chapter YIII. — Diagnosis continued . — The Localisation of the Tumour.
Chapter IX. — Pathological Diagnosis and Morbid Anatomy.

Chapter X. — Prognosis. — Duration, Course, and Termination. — ^Treatment.
Chapter XL — The Surgical Treatment of Intracranial Tumours, by A. W.
Hare, M.B., F.KC.S.Ed.

EXTRACTS FROM PRESS NOTICES,

“ Dr. Byrom Bramwell is well and widely known as a pliysician who brings the power
of careful observation, acute and impartial investigation, and lucid explanation to bear upon
many departments of medical science. In this, his latest contribution, he has taken up the
subject of Intracranial Tumours, a subject which possesses a peculiar fascination on account
of the remarkable way in which it has been elucidated by the combined progress of several
branches of medical science. The work merits coinmenilation in all jiarts, but some chapters
are more rich than others in the results of personal observation. The book does not attempt
too much, and what it does is thoroughly and well done.” — The Lancet.

“ Medical literature has gained much by Dr. Bramwell’s efforts. His latest work, on a
subject which is especially connected with the labours of many great English physicians, and
the practical treatment of which British surgeons have inaugurated and carried out so
successfully, is opportune, and at the present time particularly welcome to the medical pro-
fession. The merits of the book are manifold ; we have cliniccd experience combined with
the lucidity of expression and style of an accomplished teacher. Moreover, the author has
shown a painstaking endeavour to give the latest opinions, researches, and practical methods
of the greatest authorities on this subject. There are 116 excellent illustrations, many of
them photo-autotypes, very beautifully executed.” — The Practitioner.

“ Dr. Bramwell’s clinical memoirs are always well worthy of perusal. This one on Intra-
cranial Tumours, although its foundation is almost purely clinical, and based on the author’s
keen and exhaustive observation, is also, as embodying much generalised and philosophic
doctrine, a somewhat ambitious treatise on the whole subject of cerebral tumours. The work
is in every sense commendable. It includes the latest researches and theories, is well
balanced, dearly written, and abundantly and most admirably illustrated. The tendency of
the day is seen in the surgical bent of the book, which has its practical outcome in an
excellent chapter on surgiiSd treatment, written by Mr. A. W. Hare.” — British Medical
Journal.

Large 8vOy Cloth^ pp , 150, with 41 IllusirationSy Price 4s. 6d'

PRACTICAL MEDICINE

AND

MEDICAL DIAGNOSIS.

METHODS OF DIAGNOSIS— CASE-TAKING AND CASE-
RECORDING— MEDICAL THERMOMETRY.

BYROM BRAMWELL, M.D., F.R.CREd.,

LECTURER ON THE PRINCIPLES AND PRACTICE OF MEDICINE, AND ON I'RACTICAL MEDICINE AND
MEDICAL DIAQNOSIS, IN THE EXTRA- ACADEMICAL SCHOOL OF MI:DICTNE, EDINBURGH;

ASSISTANT I'HYSICIAN, EDINBURGH ROYAL INFIiUfARY.

(1887.)

Heady Immediately, '&vo,I>p. viii., 72, with 4 Illustrations.

THE TREATMENT OF

PLEURISY AND EMPYEMA.

BYROM BRAMWELL. M.D., F.R.C.P.Ed., F.R.S.E.

LECTURER ON THE PRINCIPLES AND PRACTICE OF MEDICINE IN THE EXTRA-ACADEMICAL
SCHOOL OF MEDICINE ; ASSISTANT PHYSICIAN TO THE
EDINBURGH ROYAL INFIRMARY.

F'^cap. folioy Price lOS. 6d. neit.

NOTE BOOK FOR

POST-MORTEM EXAMINATIONS.

BYROM BRAMWELL, M.D., F.R.CREd.,

LECTURER ON THE PRINCIPLES AND PRACTICE OF MEDICINE IN THE EXTRA-ACADEMICAL
SCHOOL OF MEDIfllNE ; ASSISTANT PHYSICIAN (FORMERLY PATHOLOGIST)

TO THE EDINBURGH ROYAL INFIRMARY.

(1883.)

In Press — 4 Vols. Royal Sw of about 1000 pages each, Illustrated with
Wood Engravings in the I'ext and numerous fullpage Plates,

Price 22s. 6 d. per Volume, Carriage Free,

VOL. 1. NOW READY.

CYCLOPAEDIA

OF THE

DISEASES OF CHILDREN,

MEDICAL AND SURGICAL

THE ARTICLES WRITTEN ESPECIALLY FOR THE WORK BY
AMERICAN, BRITISH, AND CANADIAN AUTHORS.

EDITED BY

JOHN M. KEATING, M.D.

T he Publisher has pleasure in announcing that this Cyclo-
paBdia of the Diseases of Children — the result of long
and careful consideration — is now so near completion that the
first volume can be promised this season, to be followed by the
subsequent volumes at short intervals.

The great interest which has of late been manifested in
everything that pertains to the diseases of infancy, childhood,
and adolescence is the result of the more thorough study of
disease in the adult, and the acknowledgment that in more
ways than one the child is father of the man.’^ Especially
through the investigations resulting from this interest have
physicians learned that, in order to combat successfully those
physical afflictions to which flesh is heir, the most important of
considerations is that of laying a foundation of health, strength,
and vitality in early youth.

The growth and development of the child, the diagnosis
and treatment of its diseases and injuries, and its restoration to
health after severe illness, are matters that concern every
physician. No work, therefore, can be more useful than one
which combines in short practical articles the views on these
subjects of the distinguished Physicians and Surgeons who are
devoting their time to the study of the Diseases of Children.

The aim of the Editor of these volumes has been to present
a Practical Work, appealing to the Practitioner who comes in
daily contact with disease in all its forms, as well as a Cyclo-
paedia, embodying in its many articles the Science of Medicine
and Surgery so far as they relate to the subjects in view.

Authors on both sides of the Atlantic have written articles
on the subjects with which they are most familiar, and their
views will be accepted as the latest expression of scientific
thought and practical knowledge. The endeavour throughout
has been to present valuable material in a well-digested, practical
style, written to entertain as well as instruct the reader, A brief
consideration of the subject-matter will at once show that the
general plan of the work has been so fi:amed as to render it a
complete and invaluable Text-book, as well as an unfailing Work
of Reference, to which the Practitioner may at all times turn
with the certainty of finding what he needs in its most recent
aspect.

On the part of the Publisher no effort or expense has been
spared in presenting the Cyclopaedia in a manner worthy of a
book of so great importance. The Letterpress is printed from
an entirely new fount of type, and the Contributors have been
allowed to introduce such Illustrations as they have considered
would add to the value of their contributions. These have been
reproduced in great part from original drawings and photographs,
and have been printed upon a specially prepared plate paper and
inserted as separate sheets. A large number of original Illustra-
tions and Diagrams are also included in the text.

The work, when complete, will form four handsome imperial
8vo volumes of about 1000 pages each, uniform with the System
of Gynecology and Obstetrics,” by American Authors. Each
volume will be fully indexed, and the final volume will contain
a General Index to the entire work.

As a work of which every Physician may feel proud, and
in which every Practitioner possessing it will find a safe and
trustworthy counsellor in the daily responsibilities of practice,
the Publisher reasonably anticipates a large demand.

Detailed Prospectus on application.

THE “COMPEND” SERIES.

A Series of Handbooks to assist Students preparing for Examinations.

Fourth Edition^ Revised and Enlarged^ Crown 2 >vo, pp. 233 ,
with 1 17 Illustrations^ Price 4s. 6d.

COMPEND OF HUMAN ANATOMY,

Including the Anatomy of the Viscera.

By SAMUEL O. L. POTTER, M.A., M.D.,

COOPER MEDICAL COLLEGE, SAN FRANCISCO.

Third Edition^ Revised and Enlarged^ Crown 8 vo, Cloth^ pp, 328 , Price Js. 6d.

COMPEND OF THE
PRACTICE OF MEDICINE.

By DANIEL E. HUGHES, M.D.,

LATE DEMONSTRATOR OF CLINICAL MEDICINE IN THE JEFFERSON MEDICAL
COLLEGE OF PHILADELPHIA.

Third Edition.^ thoroughly Revised, Enlarged, and Improved, Crown 8 vo,
Cloth, pp. 210 , with 91 Illustrations, Price 4s. 6d.

COMPEND OF OBSTETRICS.

By henry G. LANDIS, A.M., M.D.,

LATE PROFESSOR OF OBSTETRICS AND DISEASES OP WOMEN IN STARLING MEDICAL COLLEGE.

Fourth Edition, thoroughly Revised, Crown 8 vo, pp. 174 , with 16 Illustrations
and a Table of Physiological Constants, Price 4s. 6d.

COMPEND OF HUMAN PHYSIOLOGY.

By albert P. BRUBAKER, A.M., M.D.,

DEMONSTRATOR OF PHYSIOLOGY IN JEFFERSON MEDICAL COLLEGE.

Fourth Edition, Revised, Crown 8 vo, Cloth, pp. 118 , with 17 Illustrations,

Price 4s. 6d.

COMPEND OF SURGERY.

By ORVILLE HORWITZ, B.S., M.D.,

CHIEF OF THE OUTDOOR SURGICAL DEPARTMENT, JEFFERSON MEDICAL COLLEGE HOSPITAL.

Second Edition, thoroughly Revised, Crown 8 vo, Cloth, pp. 164 , with
7 1 Illustrations, Price 4s. 6d.

COMPEND OE THE
DISEASES OE THE EYE,

Including Refraction and Surgical Operations.

By L. WEBSTER FOX, M.D.,

OPHTHALMIC SURGEON TO THE GERMANTOWN HOSPITAL,

AND

GEORGE M. GOULD, M.D.

Foolscap %vo^ Clothe pp, viiL, 153, Price 3 s. 6d.

SYNOPSIS OF CHEMISTRY.

INORGANIC AND ORGANIC,

TO ASSIST STUDENTS PREPARING FOR EXAMINATIONS,

By THOS. W. DRINKWATER, F.C.S.,

LKCTUkER ON CHEMISTRV IN THE EDINBURGH SCHOOL OF MEDICINE.

(188a.)

In Press. — Crown 8 vo, Cloth, pp. 200, zoith Coloured Plate and
30 Wood Engravings,

HANDBOOK OF

•OBSTETRIC NURSING.

J. HAIG FERGUSON, M.B.,

CLINICAL ASSISTANT TO THE PHV.SICIAN FOR DISEASES OF WOMEN, ROYAL
INFIKM.-VKY, EDINBURGH ;

AND

FRANCIS W. HAULTAIN, M.B., F.R.C.REd

Third Edition^ iJioroughly Revised^ %vo. Cloth, pp, 172, with i6 ^ood
Efigravings, Price 7 s. 6d.

A PRACTICAL TREATISE ON

IMPOTENCE, STERILITY,

AND ALLIED DISEASES OF THE MALE SEXUAL ORGANS.

By SAMUEL W. GROSS, A.M., M.D., LL.D.,

PROFESSOR OF THE PRINCIPLES OF SURGERY AND CLINICAL SURGERY IN THE
JEFI'EKSON MEDICAL COLLEGP: OF PHILADELPHIA.

{1887.]

EXTRACT FROM PREFACE.

My aim has been to supply in a compact form practical and strictly
scientific information, especially adajDted to the wants of the general practi-
tioner, in regard to a class of common and grave disorders, upon the correction
of which so much of human happiness depends. In the Chapter on Sterility
the abnormal conditions of the semen, and the causes which deprive it of
its fecundating properties, are fully considered — portion of the work intended
to supplement the subject of sterility in the female.

8w, Cbth, pp. xy., 283, with 42 IVood Engravings, Price J>s.

THE DISEASES OF THE EAR

AND THEIR TREATMENT.

ARTHUR HARTMANN, M.D.,

BERLIN.

TRANSLATED FROM THE THIRD GERMAN EDITION BY

JAMES ERSKINE, M.A., M.B.,

SUKGSON FOR DISEASES OF THE EAR TO ANDERSON's COLLEGE DISPENSARY, GLASGOW;

LATE ASSISTANT-SURGEON TO THE GLASGOW HOSPITAL AND
DISPENSARY FOR DISEASES OF THE BAR.

(1887.)

EXTRACTS FROM PRESS NOTICES.

“ This is an admirable translation of Dr. Hartmann’s book, and reflects credit on the
transl^r. The book deserves to be widely known .”— Medical

“ Hartmann's work is perhaps one of the most popular German books on Otology. It is
short, practical, and in the main accurate. Coming, as it does, from the pen of one of the
author s scientific attainments, we need hardly say that it is well up to date. We are in
a position to welcome this work in its English dress, and to claim for it a place in the
library of all students of Otology .”— Medical Jwimal.

“The r^der will find many practical and theoretical points ably treated in this in-
te^ti^ and ^tructiye brok. The volume before us gives English readers a good insight
into the present state of Otology.” — Londx>n M^ijical Record*

Erskine has earned the thanks of all English students by translating this con-
^ original language has rapidly rewhed a third edition.”

pleasure that we notioed that this edition had been translated into
i.^ o£ G^gow, and we must congratulate him on the able manner

m ™oh he has a^mplished his task. We can recommend this translation to all interested
MjD^ofegy as being a work from which much may be learned.”— Med*-Ckvr,

Stand Edition, Revised and Enlarged, oblong Cr. Zvo, Cloth, pp. 6 $,
with 28 Illustrations, Price 4s.

THE URINE AND THE COMMON POISONS,

Memoranda, Chemical and Microscopical, for Laboratory Use.

J. W. HOLLAND, M.D.,

PROFESSOR OF MEDICAL CHEMISTRY AND TOXICOLOGY, JEFFERSON MEDICAL COLLEGE,

OF PHILADELPHIA.

- (1889.)

Cloth^ pp. xii., 285, Price

PULMONARY PHTHISIS,

ITS ETIOLOGY, PATHOLOGY, AND TREATMENT.

ALEX. JAMES, M.D., F.R.C.P.Ed.,

LECTURER ON THE PRINCIPLES AND PRACTICE OF MEDICINE IN THE SCHOOL OF MEDICINE,

Edinburgh; assistant physician, Edinburgh royal infirmary.

EXTRACTS FROM PRESS NOTICES.

“ This monograph is sure to attract a good deal of notice, and it is un-
doubtedly an excellent one. The most successful part of the book is perhaps
that which treats of nutrition as a factor in the evolution of phthisis. The
position Dr. James takes is well stated in his opening sentence, where
phthisis is said to be ‘ due to a condition of deficient nutrition, permitting the
growth and reproduction in the lung tissue of a lower form of organised life.*
. , . The treatment recommended is on the whole sound, and shows no undue
leanings. . . . There are no traces of hurried work in the book \ it is well and
forcibly written, never tedious, and its contents are well balanced. The mono-
graph will assuredly add to Dr. Jameses reputation as a sound clinical teacher.’*
— ^Thb Lancet.

“ The hook is written in strong nervous English, characterised by equal
lucidity and grace ; it therefore goes without saying that it is a pleasure to
read it. In many respects it adds considerably to our knowledge of phthisis,
especially as regards the effects of many influences at work in the causation of
the disease ; and in keeping the biological aspect of the disease steadily in
view, it must be allowed to have a real scientific import. The author is to be
congratulated on having produced a work which will greatly enhance his own
reputation and redound to the honour of the Edinburgh Medical School
Edinburgh Medical Journal.

i2W(7, Clothe pp. viii., 136, with 19 Illustrations y Price 3s. 6d.

PRACTICAL SURGERY.

MEMORANDA FOR THE USE OF STUDENTS.

W. SCOTT LANG, M.D., M.R.C.S., F.R.C.S.E.,

DEMONSTRATOR OF ANATOMY, SCHOOL OF MEDICINE, BDINBURCE

^becona .

Woodcut and 8 double-page Coloured Illustrations^ Price 2IS.

DISEASES OF THE SKIN.

A Manual for Students and Practitioners.

W. ALLAN JAMIESON, M.D., F.R.CP.Ed.,

EXTRA PHYSICIAN FOR DISEASES OF THE SKIN, EDINBURGH ROYAL INFIRMARY; CONSULTING PHYSICIAN
EDINBURGH CITY HOSPITAL; LECTURER ON DISEASES OF THE SKIN,

SCHOOL OF MEDICINE, EDINBURGH.

(1889.)

(Pentland's Medical Series, Volume First.)

EXTRACTS FROM PRESS NOTICES OF THE FIRST EDITION.

“ This is the first volume in Peniland's M&iical Series. It does credit to the author,
and is an excellent book of its kind, sound in matter, thoughtful, and practical. The work
is especially noticeable for the excellent style of the author’s writing, and for a more complete
exposition of the uses of many remedies and methods of treatment brought forward in recent
years than is to be found in any other work. Dr. Jamieson is an enthusiastic supporter of
Unna’s methods and preparations, and not without good reason. The author’s experience
on this matter will be very acceptable to the profession in these islands. After a careful
perusal of the work, we can heartily recommend it.” — The Lancet.

“ The chief charm of the work, as a whole, is its literary style. It is refreshing to read
such vigorous, lucid English, without one ambiguous line. It reminds us more of Watson’s
Physic than any more recent work. We have had the greatest possible pleasure in reading
this book. It was Lord Bacon who said that ‘ some books are to be tasted, others to be
swallowed, and some few to be chewed and digested.’ This classical work, by Dr. Jamieson,
is one of the last class, and as such we strongly recommend it to the profession.” — British
Medical Journal.

“ Dr. Jamieson’s work on Diseases of the Skin appears as the first volume of PenUoMtffs
Medical Series,, and it is difficult to imagine that a series of medical manuals could have been
introduced more successfully and with greater promise. So many manuals on diseases of
the skin have lately been published, that a new one, to possess any claim to be read, must
afford evidence of individuality. A strong claim to individuality may successfully be made
in connection with the book before us. Whilst one of its leading features is that it contains
references to the most recent works on dermatology, even up almost to the very date of
publication, it also illustrates types of skin disease and methods of treatment that have been
observed and studied by Dr. J amieson himself. It was becoming that the Edinburgh school
should produce a work of this kind, and the industry and ability of the author have con-
tributed to the production of a book which does that ancient school of medical learning
credit. We must refer the reader to the work itself, which we cordially recommend to his
consideration and study.” — Practitioner.

“ Dr. Allan Jamieson is well known to all our readers by his most valuable periscope of
Dermatology, which so often adorns our pages, as well as by much excellent original work.
The Jx)ok seems to fulfil, in a very admirable way, all the purposes for which it is intended.
It is full, yet concise enough not to be unwieldy. It is arranged in a thoroughly scientific
manner, and yet is severely practical. Without undervaluing the labours or neglecting the
classifications of other writers, Dr. Jamieson gives his own opinions, and in his own way.
Excellent illustrative cases give a personal interest to the descriptions, and each variety of
disease is so carefully painted in words as to render recognition easy ; and then the treatment,
both local and constitutional, of each is given in the plainest and easiest terms. We con-
gratulate Dr. Jamieson and the Edinburgh School, in which he is such a favourite teacher,
on his admirable work.” — Edinburgh Medical Journal.

“ If the practitioner’s library is to contain only one book on diseases of the skin, it
would be well furnished with this book.” — ^Bristol Medical Journal.

” In the limits of a short review, it would be impossible to do full justice to this im-
TOrtant tr^tise on dermati^ogy. We can strongly recommend the work as a standard text-
brok on diseases of the skin, and one which will not only prove useful to the student, but
will also serve as an excellent work of reference for the practitioner. All the illuBtratfons
are well executed.” — ^Liverpool Medic at, Journaj. *

Large 8w, Clotky pp, xvi., 600, with 147 Illustrations^ some Coloured^

Price 30s.

THE REFRACTION AND ACCOMMODATION
OF THE EYE,

AND THEIR ANOMALIES.

E. LAN DOLT, M.D.,

PROFESSOR OF OPHTHALMOLOGY, PARIS.

TRANSLATED UNDER THE AUTHORS SUPERVISION
BY

C M. CULVER, M.A., M.D.,

FORMERLY CLINICAL ASSISTANT TO THE AUTHOR; MEMBER OF THE ALBANY
INSTITUTE, ALBANY, N.Y.

(1886.)

EXTRACTS FROM PRESS NOTICES.

“ Since the publication of Bonders’ classical treatise by the New Sydenham Society,
in 1864, this is the most exhaustive work on the subject of refraction and accommodation
that has appeared in the English language, and it is of interest to observe that both are
translations.

“ Br. Landolt, as we all know, is an industrious worker, and nowhere have the results
of his close and painstaking study been recorded to better advantage than in the beautifully
printed volume before us.

“ The author has a happy faculty of simplifying things, and it finds nowhere a more
appropriate field for its employment than in the dominion of refraction.

“ As a part of his effort to make his work easy reading for the purely practical man, he
bas divided his book into three separate parts, which are in a certain measure independent
of each other, and one can be read understandingly without a thorough knowledge of the
other.” — AEOHIVES of OriiTHALMOLOGY.

“ Br. CuLVEE is to be congratulated upon the excellent translation he has produced ;
the style is always clear, and there is an entire freedom from French idiom.

“ The siyle in which the book has been published leaves nothing to be desired ; the
print and the illustrations are excellent, and the very complete index ^viU much enhance the
value of the work as a book of reference.” — Beitish Medical Jouenal.

“ This book will supply a real need, and will probably for many years be the standard
work on refraction. The work before us, while omitting nothing essential, is written in
BO clear a style, the illustrations are so numerous and well chosen, and the translation so
wdl executed, that the meaning is never obscure ; and, although mathematical formulae are
freely introduced in the physical portion, yet the plan of the b(Mk is so laid that they can be
omitted without rendering the remaining text unintelligible.

“Landolt’s Treatise is facile princes, unquestionably the best and most complete
work that has been published on the subject.” — The Peaotitioxeb.

“ English readers owe a debt of gratitude to Br. Cuivee, of Albany, for having placed
this exposition of refraction and accommodation of the eye within their reach. The text
runs as smoothly as if English were its native dress, and the fact that the translation has
been performed under the author’s supervision is scarcely needed as an assurance that this
has b^n attained without sacrifice of accuracy or precision.

“ We venture to think that, throughout, the book is really a remarkable exhibition of the
possibility of combining a high degree of scientific accuracy with lucidity of stat^ent.

“ The work is adimrably illustrated by numerous engravings, some of them coloured.
It is not useful merely for specialists, but should be found in the library of every well-
informed medical practitioner.” — Glasgow Medical Jouenal.

Large 8w, Cloth^pp, xxviii., 772, Illustrated with 404 Engravings^
Price 31S 6d.

THE PARASITES OF MAN

AND THE DISEASES WHICH PROCEED FROM THEM.

A TEXT^BOOK FOR STUDENTS AND PRACTITIONERS.

RUDOLF LEUCKART,

PROFESSOR OF ZOOLOGY AND COMPARATIVE ANATOMY IN THE UNIVERSITY OF LEIPSIC.

Translated from the German with the Co-operation of the Author,

By william E. HOYLE, M.A. (Oxon.), M.R.C.S., F.KS.E,

CURATOR OF THE MUSEUMS, OWENS COLLEGE, MANCHESTER.

NATURAL HISTORY OF PARASITES IN GENERAL.

SYSTEMATIC ACCOUNT OF THE PARASITES INFESTING MAN.

PRO TOZOA.—CESTODA .

(1886.)

EXTRACT FROM TRANSLATORS PREFACE.

Not even those reviewers who so persistently, and in many cases so
reasonably, decry the translation of German text-books, will require an apology
for an attempt to render more widely known in this country, a work which
has long since attained the rank of a classic in its native land. No pains
have been spared to present the English reader with a faithful rendering
of the original ; and the supervision which the author has exercised over
the proof sheets, not only furnishes a guarantee that he has not been mis-
represented, but has also rendered it unnecessary for me to do anything in
the w^ay of bringing the work up to the times. A number of passages, which
in the course of time had become antiquated, were cut out by the author,
who also supplied other paragraphs containing the result of more recent
researches. The few additional remarks which I have thought it necessary
to make, are in all cases indicated by my own initials.

OPINIONS OF THE PRESS.

“It is with peculiar gratification that we welcome the appearance of this classical
treatise in an English dress. Professor Leuckart is a naturalist, and he deals with the
subject from the point of view of a naturalist, but this is no disadvantage ; on the contrary, it
is a real gain, since he clearly traces the origin and nature of the various forms of Parasites,
and dwells upon their distinctive features in a way that not only imparts new knowledge,
but also points to the most effectual means for coping with these unwelcome guests of the
human body.

“ Holding the first rank among treatises upon the subject, it is to be welcomed as a great
addition to our literature. It is a book to be widely read and studied, and we may con-
gratulate Mr. Hoyle upon the excellent translation which he has effected. The numerous
illustrations add greatly to the interest and value of the text.” — The Lancet.

“ It is highly creditable that Leuckart’s classical work on Parasites should be reproduced
in this country, in a form thoroughly acceptable to English readers. Helminthology now
occupies so vast a field, that a complete treatise on this subject is likely to .assume proportions
which would place it beyond the means of the ordinary professional man, all the more so that
numerous and elaborate illustrations are an essential feature of such a volume. The publica-
tion now before us disposes of this difficulty. The book opens with several chapters on the
natural histoiy of Parasites in general, their nature and organisation, their occurrence, their
origin, their Iffe history, and their effects on man. The main portion of the work is devoted
to a systematic account of the Parasites belonging to Protozoa, and the first order of Vermes,
namely, Cestode Worms. The great and very important family of the Tape -worms and
Cysticerci thus fall for consideration in this volume, and are very elaborately dealt with.
We can confidently recommend this work.” — ^T he Pbaotitionke.

New Edition^ iSmo^ Cloth^ pp. 303, Price 4s.

STUDENTS’ POCKET

MEDICAL LEXICON.

Giving the correct Pronunciation and Definition of all Words and
Terms in general use in Medicine and the Collateral Sciences.

ELIAS LONGLEY.

(1888.)

Second Edition, Crojvn %vo, Cloth, pp. 178, Price 6s.

DOCTOR AND PATIENT.

S. WEIR MITCHELL, M.D., LLD.,

PRESIDENT OF THE COLLEGE OF PHYSICIANS, PHILADELPHIA.

CONTENTS,

(1888.)

Introductory. — The Physician. — Conyalescence. — ^Pain and its Conse-
quences. — The Moral Manajj^ement of Sick and Invalid Children. — ^5'ervous-
ness and its Influence on Character. — Out-door and Camp Life for Women.

The essaj^s which compose this volume deal chiefly with a variety of
subjects to which every physician must have given more or less thought.
Some of them touch on matters concerning the mutual relation of physician
and patient. The larger number have from their nature a closer relation to
the needs of women than of men. I was tempted when I wrote these Essays
to call them lay sermons, so serious did some of the subjects seem to me.
They touch, indeed, on matters involving certain of the most difficult problems
in human life, and involve so much that goes to mar or make character, that
no man could too gravely approach such a task, Not all, however, of these
chapters are of this nature, and I have, therefore, contented myself with a
title which does not so clearly suggest the preacher.

To be Re-issued in Ten Monthly Puts, Price te- each.
Fasciculus I. now ready.

The Atlas may also be had complete m one handsome Royal ^ Veiunu,

Extra Clothy Price 63s. nett,

ATLAS OF VENEREAL DISEASES.

A Series of Illustratiofis from Original Paintings, with Descriptions
of the varied Lesions, their differential Diagnosis
and Treatment,

P. H. MACLAREN, M.D., F.R.C.S.E.,

SURGEON, EDINBURGH ROYAL INFIRMARY; FORMERLY SURGEON IN CHARGE OF THE LOCH
WARDS, EDINBURGH ROYAL INFIRMARY; EXAMINER IN THE ROYAL
COLLEGE OF SURGEONS, EDINBURGH.

rpHE Work consists of a series of Life-size Plates, exhibit-
ing Forty-five Figures, illustrating all the essential
types of the disease in the Male and Female, including those
rarer varieties met with occasionally.

The Illustrations, without exception, are original. They
are copied from paintings of cases which have come under the
Author’s observation during tlie past few years.

The chief aim of this Work is to ofier to the Medical^
Profession a series of Illustrations which may prove useful
as a reference in the Diagnosis of Venereal Diseases.

To Medical Students who have not sufficient time nor
opportunity afibrded them in their curriculum for the system-
atic study of the multiform expressions of Venereal Diseases,
it is hoped that this Atlas will be specially serviceable.

In the production of the Plates neither labour nor ex-
pense have been spared to reproduce the original paintings
with accuracy and finish.

Each is accompanied by a concise and clear description of
the conditions portrayed.

The Atlas is printed on a thick specially prepared paper,
Folio size, 15 x 11.

To afford those members of the Profession who may desire
to secure the Work in its Serial form another opjiortunity of
acquiring it, the Publisher has decided to re-issue it in Ten
Fasciculi, at Monthly intervals. Each Fasciculus will contain
three Illustrations, with descriptive Letterpress, and along
with Fasciculus X. the Title Page, List of Illustrations, &c.
will be supplied. As but a limited number of the original
copies remain for sale, early application is recommended

Dr. MACLAREN’S

ATLAS

VENEREAL DISEASES.

LIST OF ILLUSTRATIONS.

I. — Gonorrhceal Lymphangitis. — Balanitis.

II. — Gonorrhceal Phimosis. — Gonorrhceal Paraphimosis.

III. — Gonorrhceal Warts. — Gonorrhceal Ophthalmia.

IV. — Gonorrhceal Synovitis.

V. — Chancroid (Male). — Chancroid (Female).

VI. — Chancroidal Phimosis. — Bubonic Chancroid.

VII. — Sloughing Phagadena. — Serpiginous Ulceration.

VIII. — Cicatrices after Chancroids.

IX. — Chancre (Penis), Eaw Erosion. — Chancre (Penis), Super-

ficial Ulcer.

X. — Syphilitic Phimosis. — ^Digital Chancre.

XI. — Chancre of the Xympha. — Chancre of the Labium.

XII. — Eoseolar Syphilide. — Pigmentary Syphilide.

XIII. — Papult^r Syphilide. — ^Vesicular Syphilide

XIV. — Plantar Psoriasis.

XV. — Squamous Syphilide.

XVI. — Tubercular Syphilide. — Mucous Patches and Fissures

OF the Tongue.

XVII. — Serpiginous Syphilide.

XVIII. — Eupial Syphilide.

XIX. — Ecthymatous Syphilide.

XX. — Gumma of Lips. — Sclerous Glossitis.

XXL — ^Alopecia Syphilitica. — Onychia Syphilitica
XXII. — Cicatrix after Cario-Xecrosis.

XXIII. — Mucous Syphilides. — ^Vulvar.

XXIV. — Syphilitic Eczema.

XXV. — Cario-Xecrosis.

XXVI. — Ulcerating Gummata.

XXVII. — Ano-EectaIj Syphiloma.

XXVIII. — ^Transmitted Syphilis (Early).

XXIX. — ^Transmitted Syphilis (Late).

XXX. — Early Syphilitic Xode. — Syphilitic Testicles

Large %vo Clothy pp. 701, with 214 Wood Engravings, and a
Coloured Plate, Price i8s.

THE SCIENCE AND ART OF

OBSTETRICS.

THEOPHILUS PARVIN, M.D., LL.D.,

PROFE-SSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN IN JEFFERSON
MEDICAL COLLEGE, PHILADELPHIA, AND ONE OF THE OBSTETRICIANS
TO THE PHILADELPHIA HOSPITAL.

(1887.;

OPINIONS OF THE PRESS.

“ So many obstetric manuals have been lately issued that a fresh one is
apt to be very critically received. This book, however, will at once assume a
high rank amongst the literature of this department of medicine. The enormous
amount of labour and research that has been expended on it is visible in every
chapter.

To the obstetrician one cannot over estimate the advantage of having
such a book for reference, containing as it does almost every important question
expressed or written.

“The diagrams are most excellent, many being refreshingly new and
original, and as accurate as they are graphic.

“ In conclusion, we cordially congratulate the author on the result of his
labours, which is likely to be of such real and lasting benefit to his fellow^
practitioners in all countries.” — Practitioner,

“The work proper commences with a very elaborate description of the
anatomy and physiology of the female reproductive organs. It is very care-
fully done, and the illustrations are numerous and suggestive.

“ The various stages of development of the foetus from the impregnated
ovum are particularly well described, and in addition to the stock drawings
with which every student of obstetrics is familiar, there are several which are
new to us, which aid greatly in the comprehension of this complicated process.

“ Questions such as the nutrition of the foetus in utero are discussed and
elucidated by frequent references to the most recent discoveries and hypotheses,
and the whole is worked up in a pleasant style, which is humorous without
ever being trivial.

“It is satisfactory to sec that the advantages of abdominal palpation as
an aid to the diagnosis of position are beginning to be appreciated. The details
of the procedure are given, and the modus operandi is made clear by several
woodcuts. Hitherto this valuable method has been dismissed with a few words,
and we are glad to see the lapsus filled.

“In conclusion, the book is considerably above the average work on
obstetrics, and is valuable both for study and reference. There are no less
than 215 illustrations, many of which are new, and the index is unusually
complete .” — British Medical Journal,

“Dr. Parvin is to be congratulated on the general style of his book, which
displays extensive reading as well as sound practical knowledge. The wood-
cuts, 214 in number, are lucid and well executed .” — Medical Press and Circular

PRACTICAL LESSONS IN NURSING

A NEW SERIES OF HANDBOOKS.

I^ow ready. Crown %vo. Cloth, each 4s. 6d.

THE NURSING AND CARE OF THE
NERVOUS AND THE INSANE.

By CHARLES K. MILLS, M.D.,

PROFESSOR OF DISEASES OF THE MIND AND NERVOUS SYSTEM IN THE PHILADELPHIA
POLYCLINIC AND COLLEGE FOR GRADUATES IN MEDICINE ; LECTURER ON
MENTAL DISEASES IN THE UNIVERSITY OF PENNSYLVANIA.

MATERNITY, INFANCY. CHILDHOOD.

Hygiene of Pregnancy; Nursing and Weaning of Infants;

The Care of Children in Health and Disease.

Adapted especially to the use of Mothers or those intrusted with the bringing up
of Infants and Children, and Training Schools for Nurses, as an
aid to the teaching of the Nursing of Women and Children,

By JOHN M. KEATING, M.D.,

LECTURER ON THE DISEASES OF WOMEN AND CHILDREN, PHILADELPHIA HOSPITAL.

OUTLINES FOR THE MANAGEMENT

OF DIET:

Or, The Regulation of Food to the Requirements of Health and
the Treatment of Disease.

By E. T. BRUEN, M.D.,

ASSISTANT PROFESSOR OF PHYSICAL DIAGNOSIS, UNIVERSITY OF PENNSYLVANIA ;

ONE OF THE PHYSICIANS TO THE PHILADELPHIA AND UNIVERSITY HOSPITALS.

FEVER NURSING.

Designed for the use of Professional and other Nurses, and especially
as a Text-book for Nurses in Training.

Including Fever Nursing in General, Scarlet Fever, Enteric or
Typhoid Fever, Pneumonia and Rheumatism,

By J. C. WILSON, M.D.,

VISITING PHYSICIAN TO THE PHILADELPHIA HOSPITAL AND TO THE
HOSPITAL OF THE JEFFERSON COLLEGE.

FOR SALE BY SUBSCRIPTION ONLY.

To he issued at Intervals of Two Months^ in Eight very handsome Volumes^
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Coloured Elates, Price per Volume 25s. Carriage free.

Volume I. now ready.

A REFERENCE HAND-BOOK

OF THE

MEDICAL SCIENCES,

EMBRACING THE ENTIRE RANGE OF SCIENTIFIC AND PRACTICAL
MEDICINE AND ALLIED SCIENCES BY VARIOUS WRITERS.

EDITED BY

ALBERT H. BUCK, M.D.,

NEW YORK CITY.

The Publisher has pleasure in announcing that this Work, differing from
all others issued in this country, and calculated, as he believes, from its char-
acter and the high reputation of its very large staff of learned Contributors
(over 300 in number), to be the most practical and generally useful work to all
classes of the Medicd Profession of any hitherto presented to their notice, is
so near completion that the First Volume is now ready for delivery, and the
others may be expected to appear at regular intervals of two months.

The Hand-Book consists of a collection of concisely written Essays on all
the important topics belonging to tlie broad domain of Medicine, Surgery, and
the allied Sciences. Its subject-matter is alphabetically arranged, admitting of
instant and ready reference, and is designed to cover so wide a field and em-
brace such a variety of subjects as to render it of the greatest practical utility,
■lot only to general Practitioners, but also to those who are interested in
Special Departments of Medical Science. The various Articles have been
issigned to writers who are recognised by universal consent as most competent
to handle them.

Illustrations have been freely introduced wherever they 'will serve to
elucidate the text, and special pains have been taken to secure as large a pro-
portion of Original Woodcuts as possible.

The following summary of the leading Subjects dealt with in The Hand-
Book 'will afford an idea of the extent and scope of the Work, but it is im-
possible 'within the limits of a Prospectus to do more than give a general out-
line of the contents. To secure the highest order of excellence, no labour or
expense has been spared.

SUMMARY OF CONTENTS,

Applied Anatomy. — Biology, Histology, and Experimental Physiology. — Physiological
and Pathological Chemistry. — Toxicology. — ^Pathological Anatomy. — Hygiene and Public
Health. — Military and Naval Medicine, Hygiene and Sanitary Science. — Climatology, Health
Resorts, and Mineral Springs. — Life Insurance. — Medical Jurisprudence. — General Pathology
and Therapeutics, and Physical Diagnosis. — Materia Medica, Medical Botany, and Pharma-
cology. — Poisonous Insects and Reptiles. — Surgical Pathology and General Surgery. —
Orthopsedio Surgery. — Dental Pathology and Therapeutics. — ^Diseases of the Mind and
Nervous System. — Dermatology and Syphilis. — Laryngology and Diseases of the Nose and
Throat. — Ophthalmology. — Otology. &o. &c.

8 w, Clothe pp, xvi., 271, with Coloured Plates and 35 Engravings^
Price lOS. 6d.

THE CAUSES AND TREATMENT

ABORTION.

ROBERT R. RENTOUL, M.D., M.R.C.S.,

FELLOW or THE OBSTETRICAL SOCIETY, LONDOK.

WITH AN INTRODUCTION BY

LAWSON TAIT, F.R.C.S.

Zvo, Cloth, pp. 212, with 23 Plates and 19 Engravings, Vol. /., Price 7 s. 6d. nett.

REPORTS FROM THE LABORATORY

OF THE

ROYAL COLLEGE OF PHYSICIANS, EDINBURGH.

EDITED BY

J: BATTY TUKE, M.D.,

AND

G. SIMS WOODHEAD, M.D.

CONTENTS.

1. Notes on the Equipment of the Laboratory. By G. Sims Woodhead, M.D., F.Il.S.Ed.
— 2. Sectional Anatomy of Advanced Extrauterme Gestation. By D. Berry Hart, M.D.,

F. R.C.P.Ed., and J. T. Carter, F.R.O.S.Ed., F.F.P.S.G. [Plates I., II., and III.]^. Notes
on the use of Mercuric Salts in Solution as Antiseptic Surgical Lotions. By G. Sims Wood-
head, M.D., F.R.8.Ed. — 4. The Mechanism of the Separation of the Pla^nta and Mem-
branes during Labour. By D. Berry Hart, M.D., F.R.C.P.Ed. [Plates IV. and V.]---6.
On the Secretion of Lime by Animals. By Robert Irvine, F.C.S., F.R.S.Ed., and G. Sims
Woodhead, M.D., r.R.S.Ed. — 6. On a Case of Absence of the Corpus Callosum in the
Human Brain. By Alexander Bruce, M.D., F.R.S.Ed. [Plates VI. to XVH.] — 7. The
Air of Coal Mines. By T. G. Nasmyth, M.B., D.Sc., Edin., F.R.S.Ed. [Plate XVin.
— 8. Cystic Disease of the Ovaries. By J. W. Martin, M.D. — 9. Histological Observations
on the Muscular Fibre and Connective Tissue of the Uterus during Pregnant^ and the
Puerperium. By T. Arthur Helm, M.B., Edin. [Plate XIX.] — 10. Abstract of tne Result
of an Inquiry into the Causation of Asiatic Cholera. By Neil Madeod, M.D., Edin., and
Walter J. Miller, F.R.C.S.Eng. — 11. Tabes Mesenterica and Pulmonary Tuber^osis. By

G. Sims Woodhead, M.D., r.R.S.Ed., Sanitary Research Scholar of the Hon. The Grocers*
Company, London. [Plates XX. to XXIII-]

8tw, Chth, pp. xii., 302, with 5 Wood Et^gramnis, Price 9$.

DISEASES OF THE MOUTH, THROAT,
AND NOSE,

INCLUDING

RHINOSCOPY AND METHODS OP LOCAL TREATMENT.

PHILIP SCHECH, M.D.,

LECTUREB IN THE UNIVERSITr OF MUNICH.

TRANSLATED BY

R. H. BLAIKIE, M.D., F.R.S.E.,

FORMERLY BURGEON, EDINBURGH EAR AND THROAT DISPENSARY ; LATE CLINICAL ABSISXANT,

EAR AND THROAT DEPARTMENT, ROYAL INFIRMARY, EDINBURGH.

(1886.)

EXTRACTS FROM PRESS NOTICES.

“We have read this book with great interest. It is altogether a work of much practical
value, and will well repay perusal by the practitioner.” — The Practitioner,

“ We can heartily recommend this work.” — Birmingham Medical Review.

“The translator has succeeded in rendering available to English readers a manual
most useful for their guidance, and which has long been a desideratum. It is handsomely
produced, and is furnished with a very good index.” — Hospital Gazette.

Zvo, Cloth, pp. 285, with 1 17 Wood Engravings, Price lOS. 6d.

A MANUAL OF

TREATMENT BY MASSAGE,

AND METHODICAL MUSCLE EXERCISE.

By JOSEPH SCHREIBER, M.D.,

MEMBER OF K.K. OESELLSOHAFT DER AERTZE OF VIENNA ; FORMERLY DOCENT
IN THE UNIVERSITY OF VIENNA.

TRANSLA TED WITH THE A UTHOR'S PERMISSION

By WALTER MENDELSON, M.D.,

OF NEW YORK. (X887.)

EXTRACT FROM THE PREFACE.

My object in writing this work has been to afford the Practising Physician
a trusty guide to the mechanical treatment of disease. Throughout it has been my
endeavour to elucidate the mechanical method by citations of cases which have
come within my personal observation, and to call attention to both peculiar
and unforeseen difi&culties, as well as to introduce, wherever possible, such
practical hints as will facilitate the execution of the various manipulations.

Sw, Cloth, pp. xii, 223, with 7 illustrations, Price 9s.

ELEMENTS OF

PHARMACOLOGY.

Dr. OSWALD SCHMIEDEBERG,

PROFESSOR OP PHARMACOLOGY, AND DIRECTOR OF THE PHARMACOLOGICAL
INSTITUTE, UNIVERSITY OP STRASSBURG.

TRANSLATED UNDER THE AUTHOR’S SUPERVISION BY

THOMAS DIXSON, M.B.,

LECTURER ON MATERIA MEDICA IN THE UNIVERSITY OP SYDNEY, N.S.W. (ifi

SUMMARY OF CONTENTS.

Introduction.

Chapter I. — Xerve and Muscle poisons.

Chapter II. — Substances which through their molecular properties cause
alterations of various kinds at the point of application.

Chapter III. — The action of water and of saline solutions.

Chapter IY. — Chemical cauterisation by means of acids, halogens and
oxidising substances.

Chapter Y. — The compounds of the heavy metals, and aluminium as
nerve poisons, muscle poisons, and escharotics.

Chapter YI. — The general actions of the aromatic compounds.

Chapter YII. — Digestive ferments and food stuffs.

Chapter YIII. — Kemedies acting mechanically and physically.

EXTRACT FROM TRANSLATORS PREFACE,

“ The great reputation enjoyed by the Author of this work is a sufficient reason for the
following translation. .

“Although in each section only the leading remedi^ belong^ to the German
Pharmacopoeia have been mentioned, yet the list takes into consideration all of real
importance, and is therefore applicable to most works of the kind.

“By the kind consent of Professor Sohmiedebbrg, various Tracings have been mtro-
duced. All of these have been execut^ under his personal superintendence, and are the
results of original work carried out in his Laboratory at Strassburg.

“ To the great interest taken by him in correcting and revising the ^nslation, as well
as in bringing it up to date as regards recent investigations, I am greatly indebted.

EXTRACTS FROM PRESS NOTICES,

“We entertain a very high opinion of this book. If the views that it presents of
the real value of many drugs in common use are different from our own, and often dis-
couraging, there is the more reason that we should make ourselves acquainted with them,
coming as they do from so high an authority. All of us must coiffess that in therapeutics,
at least, advance must come as well in the direction of imleaming and forgetting
of what we have been taught, as in that of acquiring fresh knowledge of a positive hind.
To all who are of this opinion, and who we interested in establishing a more stable
foundation for our methods of treatment than we can at present claim, we ^mestiy
recommend this work, from which, better than from any other work we know,
be able to form a correct estimate of the present position of our ^ence. The Enghsh
edition is in the form of a handsome, beautifully printed volume, which it is a ^leawire to
possess. Dr. Dixson deserves cr^it for the carefulness of his translation. The

Practitioner, , . , . n

«... We venture to prophesy a great success for this, the most generally
useful book on the subject we have as yet seen. The author seems to have exhausted
Buropean medical literature for his facts, and we are glad to see acknowledgment always
made to the quoted author. The good index which the book has adds greatly to ^ its
value, and to those engaged in actual practice we heartily commend the * Phajmwxnc^ as
one of the most valuable books on drugs published during the decade .” — Medical

“We can speak in the very highest terms of the mtrinsio merits of the work. The
translation is very good.” — LwerpooL M&Aico-Chinirgioal Journal,

Crown 8 vo, Cloth, pp. xii., 173, with 60 Illustrations, Price 55.

MANUAL OF CLINICAL DIAGNOSIS.

Br Dk. otto SEIFERT.

PBIVAT DOCENT IN WURZBURG,

AND

Dr. FRIEDRICH MULLER,

ASSISTANT DER II. MEd! KLINIK IN BERLIN.

THIRD EDITION REVISED AND CORRECTED. TRANSLA TED WITH THE
PERMISSION OF THE AUTHORS,

By william B. CANFIELD, A.M. M.D.,

CHIEF or CLINIC FOR THROAT AND CHEST, UNIVERSITY OF MARYLAND.

(I88^

EXTRACT FROM TRANSLATOR’S PREFACE.

The favour with which this book has been received in Germany, and
its eminently practical and concise manner of dealing with the different
important points in diagnosis, seem to justify its translation into English.
It has been brought down to the latest acquisitions of science, thus repre-
senting the most advanced views. For the sake of clearness, the figures
relating to weight, measure, length, etc., as well as the dose table at the
end of the book, have been modified to conform to the system used in
England and America.

Large 8 vo, Cloth., pp. 270, Illustrated with 13 Plates, mostly Coloured,

Price 9s.

SURGICAL BACTERIOLOGY.

NICHOLAS SENN, M.D., Pii.D.,

PROFESSOR OF PRINCIPLES OF BURGF.RY AND SURGICAL PATHOLOGY, RUSH MEDICAL
COLLEGE, CHICAGO.

(1889.)

EXTRACT FROM PREFACE.

Within a few years bacteriology has revolutionised surgical pathology.
All woimd complications, and most of the acute and chronic inflammatory
lesions which come under the treatment of the surgeon, are caused by micro-
organisms ; hence the necessity of a proper recognition of the importance of
bacteriology as an integral part of the science and practice of modem surgery.
It has been the endeavour of the author to present the different subjects
contained in this work in as concise a manner as possible, and at the same
time to omit nothing which might be deemed necessary to impart a fair
knowledge of the subject.

Second £dtfton, Crown Zvo^ extra Cloth^ pp. xvi., 287, Price 3s. 6d.

THE LIFE AND RECOLLECTIONS OF
DOCTOR DUGUID

OF KILWINNING.

WRITTEN BY HIMSELF^ AND NOW FIRST PRINTED FROM THE
RECOVERED MANUSCRIPT.

JOHN SERVICE, L.R.C.S & P. Ed., Sydney.

(1888.)

New and thoroughly Revised Edition^ large Clothe pp. 877,
Illustrated with over 1000 Wood Engravings^ Price 24s.

THE PRINCIPLES AND PRACTICE OF
OPERATIVE SURGERY.

By STEPHEN SMITH, A.M., M.D.,

PROFESSOR OP OlilNICAL SURGERY IN THE UNIVERSITY OF THE CITY OF NEW YORK; SURGEON
TO BEULEVUE AND ST. VINCENT HOSPITALS, NEW YORK.

EXTRACTS FROM PRESS NOTICES.

“ This work is too well and too favourably known to require any words of commendation,
and its merits effectually protect it against adverse criticism. It is not a manual of
operative surgery, but a treatise upon the principles as well as the practice of mechanical
surgery. The subject-matter is brought down to the very latest period, hence we find the
work to be a faithful exponent of the art of surgery as it is practised now. We may be
allowed to say that Stephen Smith’s Operative Surgery is one of the most complete
works in the English language, and is a fit companion to Malgaigne’s magnificent
treatise, after which it is patterned. The work reflects great credit upon the author.” —
The International Journal of Medical Science.

Crown 4to, extra Clothe gilt top, with 70 Plates exhibiting
over 400 Figures, Price I 2 S. 6d,

ILLUSTRATIONS OF ZOOLOGY,

INVERTEBRATES AND VERTEBRATES.

By william RAMSAY SMITH B.Sc.,

DEMONSTRATOR OF ZOOLOGY IN THE UNIVERSITY OF EDINBURGH.

AND

J. STEWART NORWELL.

EXTRACT FROM PREFACE.

(1889.)

This book is a companion to a course of Systematic Zoology. In it the student will
find illustrated by Diagram or Drawing, the structure of forms selected from all the great
classes of Vertebrates and Invertebrates, and the illustrations arranged in systematic
order. Our design is to help the student of Comparative Anatomy in the most important
and most difficult part of a systematic course of lectures.

Second Edition^ Crown 8w, Cloth^pp, 674, with 117 luustrations^
Price 15s.

DISEASES OE WOMEN.

A HANDBOOK FOR PHYSICIANS AND STUDENTS,

By Dr. F. WINCKEL,

PROFESSOR or GYNiBOOLOGY, AND DIRECTOR OP THE ROYAL UNIVERSITY CLINIC FOR
WOMEN, IN MUNICH.

AUTHORISED TRANSLATION BY

J. H. WILLIAMSON, M.D.,

RESIDENT PHYSICIAN, GENERAL HOSPITAL, ALLEGHENY, PENNSYLVANIA.

UNDER THE SUPERVISION, AND WITH AN INTRODUCTION BY

THEOPHILUS PARVIN, M.D.,

PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN IN JEFFERSON MEDICAL
COLLEGE, PHILADELPHIA; AUTHOR OF *^TH£ SCIENCE AND ART OF OBSTETRICS.”

(1889.)

OPINIONS OF THE PRESS.

“ Dr. Winckel’s work well deserved translation into EngUsh. A very large number
of treatises and text-books on G3m8ecology have been written by distinguished British and
American authors, but hardly one of the type of Dr. Winckel’s Diseases of Women. The
best English works on this subject are all clinical and surgical, rather than pathological,
and the personal element is ever predominant, experience being put before tradition even
of the soundest kind. Diseases of Women is a text-book where pathology is placed
throughout in the foremost position. The chief feature of excellence is a complete and
uniform harmony of the synthetical and analytical aspects of the subject. Anatomical
parts and their diseases and malformations are fully classified, and each disease is de-
scribed in detail. Rare conditions are not omitted, trifling affections are carefully noted,
yet too great prominence is not given to either, so that the reader learns about a rarity
without acquiring an exaggerated idea of its importance, and reads about a trifle so
as to discover that the trifle is a fact, though none the less trifling on that account.
In short, a sense of due proportion is conveyed to the student of Diseases of Women
by the excellent literary method of its author. The translator has done his work well.
Dr. Williamson has mastered a difficult task, as German translation is not easy even
to German scholars, and Diseases of Women is not a very small book. His labours will
not be in vain, for he has done English medical readers a service.” — British Medical
Journal.

“ The thanks of the profession are due to Dr. Williamson for translating the work
into English in such excellent style. The task was xmdertaken at Dr. Parvin’s suggestion
and under his supervision, and the value of the work is much enhanced by his extremely
suggestive and interesting introduction. Prof. Winckel has devoted much space to
Pathology, a part of Gynsecological research till recently greatly neglected in England —
and this alone will ensure his book assuming a first place in the literature of the subject.
The last chapter is devoted to the Diseases of the Female Breast, and is a very welcome,
if somewhat unusual addition to such a work. We congratulate Dr. Parvin upon having
formed such a right estimate of this book, and both Dr. Williamson and himself for the
prompt measures they took to bring it within the reach of all English readers.” — The
Praotitionbr.

8 w, pp» xvi, 534, Illustrated with 162 Coloured Plates^ mostly

from Original Drawings^ Price 24s.

SECOND EDITION, REVISED AND IN PART RE-WRITTEN.

PRACTICAL PATHOLOGY:

A MANUAL FOR STUDENTS AND PRACTITIONERS.

G. SIMS WOODHEAD, M.D., F.R.CP.Ed.,

TOBMBBLY DEMONSTRATOB OF PBAOTIOAL PATHOLOGY IN THE UNIVEESITY
OP EDINBUBGH ; PATHOLOGIST TO THE ROYAL INFIRMARY,
EDINBURGH.

(I88S-)

ABRIDGED LIST

Chap. I. Post-mortem Examination.

„ II. Pathological Histology.

„ III. The Liver.

„ IV. The Heart.

„ V. Blood-Vessels.

„ VI. The Kidney.

„ VII. The Lung.

„ VIII. The Spleen.

OF CONTENTS.

Chap. IX. The Alimentary Canal

„ X. Bone and Joints.

„ XI. Nervous System.

„ XII. The Organs of Generation

in the Female.

„ XIII. Tumours.

„ XIV. Animal ParasiteB.

„ XV. Vegetable Parasites.

OPINIONS OF THE PRESS ON SECOND EDITION.

From the Lancet. — “ The comparatively brief interval that has elapsed
since the publication of the first edition of this book shows that its merits
have been well appreciated, for it occupies almost a unique position, and
constitutes a thoroughly trustworthy guide in pathological research. The
number of the illustrations, which, it may be remembered, are coloured so
as to reproduce the appearances of the stained preparations from which they
were drawn, has been increased. It is not difficult to predict for the book
an enduring success.”

From the Medical Times. — “ The appearance of a new edition within
so short a time of its original production is a sufficient sign that this work
has succeeded in laying hold of that fickle thing — ^public favour ; and so far
as the general preparation of the work is concerned, it fully deserves the
success attained.”

From the Bristol Medical Journal. — “ The very high opinion as to
the merits of this work, which we have already expressed, has been more
than confirmed by the rapid call for a new edition. Careful revision, the
re-writing of some parts, and the addition of much new matter, have still
further added to the excellence of the work.”

From the Medical Chronicle. — “ This book has deservedly won for
itself a position, and successfully fills a gap in pathological literature. We
can assure our readers who are still unacquainted with this elegantly bound
book, full of fascinating many tinted illustrations, that it is not only beauti-
ful, but good, and invaluable to beginners in the patholo^cal laboratory.”

8w, Cloth, pp. xii., 174, with 60 Illustrations, mostly Original in Colours)

Price 8s. 6d.

PATHOLOGICAL MYCOLOGY:

AN ENQUIRY INTO THE ETIOLOGY OF INFECTIVE DISEASES.

G. SIMS WOODHEAD, M.D., F.R.C.P.Ed.,

DIBEOTOR OF THE PATHOLOGICAL LABORATORY, ROYAL COLLEGE OF PHYSICIANS, EDINBURGH.

AND

ARTHUR W. HARE, M.B., CM.,

PROFESSOR OF SURGERY, OWENS COLLEGE, MANCHESTER.

SECTION I.— METHODS. (1885.)

OPINIONS OF THE PRESS,

From the Lanoet. — “This is essentially a laboratory hand-book, and its publication
should do much to extend rhe knowledge of the methods employed in the detection,
differentiation, and cultivation of septic and pathogenetic micro-organisms, which claim
so much attention in the present day. The chapters devoted to ‘ Methods ’ are particu-
larly detailed and precise, so that no one who faithfully follows the directions given can fail
to attain results which are as convincing in their demonstration of the specific differences
of these minute organisms as they are simple in the production. Too much praise can
hardly be awarded to the very beautiful coloured drawings, particularly those of various
potato and gelatin cultures ; they form a special feature of the work, and in their fidelity
supplement in an admirable maimer the descriptions of the text. The authors will have no
reason to regret the time and labour expended on the production of their work, which is
sure to be widely read and appreciated.”

From the Medical Press. — “ Bacillus culture is the humour of the age, and the
publication of the volume before us is a wisely conceived and practical interpretation of
the spirit of the times. While it is possible that, in certain quarters, too great significance
has been ascribed to micro-organisms as etiological factors in disease, it is only right that
every encouragement be given to the exact study of the question, that we may sift the
known from the problematical, and by a (ireful induction obtain clearer and broader
views than those at present possible. This is essentially the aim of the present work, and
we gladly welcome its appearance. The volume is richly and beautifully illustrated by
numerous drawings in colour and black and white. They are certainly the finest which
have yet been offered to the student in this field of the scientific world. It is the best
guide to the subject with which we are acquainted, either in English or in any other
language.”

From the Birmingham Medical Review. — “Whatever may be the ultimate position of
miaro-oiganisms in pathology, it must be conceded that their study is at the present time
the duty of pathological investigators, and therefore a medical guide to the methods of this
enquiry is an opportune publication, especially when, as in the present instance, it is the
work of experts. The present volume deals solely with the methods to be employed. It is
admirably arranged, giving very full details of all necessary apparatus, etc., as well as good
drawings of the different organisms. We can warmly recommend it to all students of
Mycology.”

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